cms_TN
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| Link | rowid | facility_name | facility_id | address | city | state | zip ▼ | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 719 | 719 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2019-01-08 | 842 | D | 1 | 0 | KGXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to maintain complete and accurate medical record for 1 resident (#1) of 3 records reviewed. The findings include: Review of the facility policy, Medication Administration, dated 1/15/12, revealed .Medications shall be administered .as prescribed .The individual administering the medication must initial the resident's Medication Administration Record (MAR) on the appropriate line after giving the medication . Medical record review revealed Resident #1 was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. The resident was discharged to an acute hospital on [DATE]. Medical record review of Resident #1's Pain Tool form dated 12/6/18 revealed the location of pain in right and left knees (front), pain was relieved by Tylenol 650 milligrams, effected the resident's sleep, social and physical activities/mobility, and emotions; and pain was made worse with movement and weather change. Medical record review of Physician Orders dated 12/6/18 revealed .Aspirin 81 milligrams (mg) 1 time daily for pain related to fracture, Monitor pain every shift, and Tylenol 325 mg Give 2 tablets every 8 hours as needed (PRN) for pain/fever . Medical record review of the Pain Interview form dated 12/13/18 revealed Resident #1 had occasional pain in last 5 days; pain did not make it hard to sleep; pain did limit day-to-day activities in past 5 days; intensity of pain 5 out of 10; indicators of pain/possible pain-vocal complaints; frequency with which resident complains or shows evidence of pain or possible pain-3 to 4 days; .Treatment .Received PRN pain medication-[MEDICATION NAME] 325 mg (milligrams) give 2 tablets po (by mouth) every 8 hr (hours) as needed-effective .Receive non-pharmaceutical intervention-Repositioning, Dim Light/Quiet environment, sometimes not effective (12/9, 12/10); Comments - resident has moderately cognitive impairment which can affec… | 2020-09-01 |
| 720 | 720 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2017-02-16 | 157 | D | 0 | 1 | BNS411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, the facility failed to obtain a discharge to hospital order for 1 resident (#4) of 30 residents reviewed and failed to obtain a physician order for [REDACTED]. The findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nursing note dated 1/16/17 revealed Resident #4 was transferred to the hospital for pain. Medical record review revealed no physician order to transfer the resident to the hospital. Further review revealed a physician order dated 1/18/17 .Return from hospital . Interview with Licensed Practical Nurse (LPN) #4 on 2/14/17 at 9:04 AM in the conference room confirmed the facility failed to obtain a physician order for [REDACTED]. Medical record review revealed Resident #14 was admitted to the facility on [DATE], and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 2/13/17 at 11:00 AM and on 2/14/17 at 11:12 AM revealed a C-Pap mask stored on the bed side table in Resident #14's room. Medical record review of the physician orders revealed no order for the C-Pap setting. Interview with LPN #3 on 2/15/17 at 8:12 AM at the nursing station revealed the staff turned the machine on and off per the direction of the resident and gave him the mask to put on. Further interview confirmed the facility failed to obtain the C-Pap setting order. | 2020-09-01 |
| 721 | 721 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2017-02-16 | 225 | D | 0 | 1 | BNS411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, and interview the facility failed to report allegations of abuse in a timely manner for 3 residents (#20, #31, #102) of 5 residents reviewed for abuse and failed to complete a thorough investigation for an injury of unknown origin for 1 resident (#20) of 5 residents reviewed for abuse. The findings included: Review of facility policy, Accidents/Incidents Investigations, revised 6/1/12 revealed, .The facility will investigate and report all accidents/incidents in accordance with State and Federal Regulations . Review of facility policy, Abuse Investigations, revised 6/1/12 revealed, .All reports of .injuries of an unknown source shall be promptly and thoroughly investigated by facility management .the investigation should, at a minimum .determine events leading up to the incident; Interview the person (s) reporting the incident .interview the resident .interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .A facility incident report should be filled out and all supporting documentation filed with the incident report . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact and exhibited no signs or symptoms of [MEDICAL CONDITION] or behaviors. The resident was totally dependent requiring assistance of 2 or more people for bed mobility and transfers. Continued review revealed the resident had no falls since the prior assessment on 11/21/16. Review of a facility investigation dated 12/15/16 for Resident #20 revealed the resident was sitting at the nurse station complaining of left knee pain. An X-ray was ordered and revealed a [MEDICAL CONDITION] distal femur. Continued review revealed the investigation did not cont… | 2020-09-01 |
| 722 | 722 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2017-02-16 | 226 | D | 0 | 1 | BNS411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review and interview the facility failed to follow it's own policy for investigating allegations of abuse for 1 resident (#20) of 5 residents reviewed for abuse. The findings included: Review of facility policy, Accidents/Incidents Investigations, revised 6/1/12 revealed, .The facility will investigate and report all accidents/incidents in accordance with State and Federal Regulations . Review of facility policy, Abuse Investigations, revised 6/1/12 revealed, .All reports of .injuries of an unknown source shall be promptly and thoroughly investigated by facility management .the investigation should, at a minimum .determine events leading up to the incident; Interview the person (s) reporting the incident .interview the resident .interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .A facility incident report should be filled out and all supporting documentation filed with the incident report . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact and exhibited no signs or symptoms of [MEDICAL CONDITION] or behaviors. The resident was totally dependent requiring assistance of 2 or more people for bed mobility and transfers. Continued review revealed the resident had no falls since the prior assessment. Review of facility investigation dated 12/15/16 revealed Resident #20 was sitting at the nurse station complaining of left knee pain. Continued review revealed an X-ray was ordered and revealed a [MEDICAL CONDITION] distal femur. Continued review revealed the investigation did not contain any statements from the resident or staff providing care to the resident. Further review revealed there was no determination as to the… | 2020-09-01 |
| 723 | 723 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2017-02-16 | 363 | F | 0 | 1 | BNS411 | Based on observation, review of the meal spread sheet identifying the portion control for food served, and interview, the facility failed to serve resident food according to the spread sheet for 1 of 2 meals served. The findings included: Observation of the resident mid-day meal trayline in progress in the dietary department on 2/13/17 at 11:43 AM, revealed a dietary staff member serving food from the steam table. Further observation revealed one resident tray delivery cart had left the dietary department. Further observation revealed dietary staff member #1 serving pureed textured meat and pureed vegetables with #12 (1/3/cup) scoops and mashed potatoes with a #10 (2/5 cup) scoop. Review of the spread sheet for the mid-day meal revealed the serving (portion) sizes of pureed meat was to be a #8 (1/2 cup) scoop, pureed vegetables a #10 (2/5 cup) scoop and mashed potatoes was a #8 (1/2 cup) scoop. Interview with the Registered Dietitian and the cook on 2/13/17 at 11:43 AM by the trayline confirmed the portions for pureed meat and vegetables and the portion for mashed potatoes served to the residents were less than the portion size documented on the spread sheet. | 2020-09-01 |
| 724 | 724 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2017-02-16 | 371 | F | 0 | 1 | BNS411 | Based on observation and interview, the facility failed to ensure dietary staff facial hair was covered in the food production and food service areas; failed to serve food in a sanitary manner for 1 of 2 meals observed; failed to maintain food production equipment in a sanitary manner; and failed to ensure the dish racks were not stacked in the dish machine, the trays were dry and free of debris prior to storage, and the staff did not cross contaminate from the dirty to clean side of the dish machine. The findings included: Observation on 2/13/17 at 11:43 AM in the dietary department of the resident mid-day meal tray line in progress, revealed bearded male dietary staff server #1 serving food from the steam table without wearing a facial cover. Further observation revealed one resident tray delivery cart had left the dietary department and the dietary member continued serving food on the resident trayline. Interview with the Registered Dietitian and the cook on 2/13/17 at 11:43 AM by the trayline confirmed the bearded male dietary server #1 failed to cover the facial hair in the food service area while serving the residents mid-day meal. Observation on 2/13/17 at 12:15 PM in the dietary department, with the Registered Dietitian and cook present, revealed the following: 1. 6 of 12 hood filters had an accumulation of brown colored debris on the grill and convection oven side of the hood. 2. The interior of the hood had numerous streaks from the top to the bottom of the hood and an accumulation of debris. 3. The grill spill pan had an accumulation of food debris and liquid. Interview with the cook on 2/13/17 at 12:15 PM by the grill revealed the grill was .last used sometime last week . Further interview confirmed the facility failed to clean the grill spill pan after use. Observation on 2/13/17 at 5:00 PM in the dietary department, with the Registered Dietitian and cook present, of the evening resident meal service, revealed the server on the trayline wearing gloves on both hands. Further observation revealed the s… | 2020-09-01 |
| 725 | 725 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2017-02-16 | 372 | F | 0 | 1 | BNS411 | Based on observation and interview, the facility failed to contain the facility waste in 1 dumpster of 2 dumpsters observed. The findings included: Observation on 12/13/17 at 8:00 AM and at 1:30 PM revealed 2 sealed plastic bags and 2 cardboard boxes on the top lid of the dumpster on the right side of the 2 exterior dumpsters. Interview with the Administrator on 2/13/17 at 8:10 AM in the dietary hallway confirmed the facility failed to contain the facility waste appropriately. | 2020-09-01 |
| 726 | 726 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2017-02-16 | 412 | D | 0 | 1 | BNS411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide dental care for 1 resident (#71) of 30 residents reviewed. The findings included: Medical record review revealed Resident #71 was admitted to the facility 6/1/15 with [DIAGNOSES REDACTED]. Observation and interview with the resident on 2/14/17 at 2:52 PM, in the resident's room revealed the resident had no natural lower teeth and an upper denture plate. Interview with Resident #71 revealed she lost her lower denture plate and had told the staff she wanted to see a dentist but had not seen one. Continued interview with Resident #71 revealed her roommate had seen a dentist but she had not. Interview with the Social Worker (SW) on 2/15/17 at 9:50 AM in the Social Services office confirmed the resident had been scheduled to see the dentist on 10/27/16, however, the appointment was canceled by the Dentist's office due to incomplete paperwork. Continued interview revealed the SW confirmed the facility failed to provide dental care for Resident #71. | 2020-09-01 |
| 727 | 727 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2017-02-16 | 441 | F | 0 | 1 | BNS411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, interview, and employee record review, the facility failed to maintain a Continuous Positive Airway Pressure (C-Pap) mask in a sanitary manner for 1 resident (#14) of 1 resident reviewed for use of a C-Pap machine and failed to have documentation facility staff were offered the Hepatitis B+ vaccine for 8 of 8 employee records reviewed. The findings included: Review of facility policy, Ventilator Equipment Storage: Bi-Pap (Bilevel Positive Airway Pressure), C-Pap, Nebulizer dated 10/1/10 revealed .The purpose of this procedure is to ensure the resident's equipment is cleaned, disinfected and stored properly between usage .The mask will be stored in a zip lock bag. The zip lock bag will be dated . Medical record review revealed Resident #14 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of the resident's room on 2/13/17 at 11:00 AM revealed a C-Pap mask in contact with a urinal stored on the bed side table. Observation of the resident's room on 2/14/17 at 11:12 AM, with the Director of Nursing present, revealed the C-Pap mask in contact with the urinal stored on the bed side table. Interview with the Director of Nursing on 2/14/17 at 11:12 AM in Resident #14's room confirmed the facility failed to store the C-Pap mask in a sanitary manner and per facility policy. Interview with Resident #14 on 2/15/17 at 7:45 AM in his room revealed he had used the C-Pap on Sunday night, 2/12/17, only. Further interview revealed the staff handed him the mask, he positioned the mask on his face and the staff turned on the machine. Further interview revealed the resident could remove the mask and the staff took the mask and turned the machine off. Interview with Licensed Practical Nurse #3 on 2/15/17 at 12:00 PM at the nursing station revealed Resident #14 required assistance with the C-Pap. Further interview revealed the s… | 2020-09-01 |
| 728 | 728 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2018-04-18 | 578 | D | 0 | 1 | 24XE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain accurate advanced directives (code status) in the electronic medical record for 1 of 42 sampled residents (Resident #86) reviewed. Findings include: Medical record review revealed Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the electronic medical record for Resident #86 on [DATE] at 4:10 PM and [DATE] at 9:50 AM revealed the resident's advanced directive (codes status) was Cardiopulmonary Resuscitation (CPR) indicating she preferred life saving interventions if she has no pulse and is not breathing. Medical record review of Resident #86's hard chart revealed a POST (Physician order [REDACTED]. Interview with the charge nurse, Licensed Practical Nurse (LPN) #5 on [DATE] at 9:50 AM at the nurses station after viewing Resident #86's, home page on the electronic medical record and the hard chart copy of the POST form confirmed the electronic medical record and hard copy POST form were not the same. Further interview confirmed the hard copy POST form was the correct document to follow. The LPN (#5)confirmed the facility failed to maintain accurate code status for Resident #86 in the electronic medical record. | 2020-09-01 |
| 729 | 729 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2018-04-18 | 580 | G | 0 | 1 | 24XE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, Physician Order, Nurse's Notes, Radiology Report and interview, the facility failed to notify the Medical Director/Attending Physician immediately after 1 fall by 12 residents (Resident #239) sampled/reviewed for falls. The facility's failure to notify the Physician in a timely manner resulted in prolonged pain to the Resident and HARM (a situation in which the provider's noncompliance resulted in a negative outcome that had compromised the resident's ability to maintain and/or reach his/her hightest practical physical, mental and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care and provision of services). Findings include: Review of facility policy Notification of Physician & Family - Change in Resident's Condition or Status revised 11/28/16 revealed, .Our facility shall promptly notify the .Attending Physician .of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's Attending Physician .when there has been a(an) .accident or incident involving the resident . Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum (MDS) data set [DATE] revealed Resident #239 had a Brief Interview for Mental Status score of 11, indicating mild cognitive impairment and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene and required total dependence for bathing. Continued review revealed the resident was not steady and only able to stabilize with staff assistance for moving from a seated to standing position. Further review revealed Resident #239 was at risk for falls and had a fall with major injury since admission (3/23/18). Review of a facility investigation dated 3/26/18 revealed Resident #239 had a… | 2020-09-01 |
| 730 | 730 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2018-04-18 | 600 | G | 0 | 1 | 24XE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Nurse's Notes, Physician's Orders, review of facility investigation and interview, the facility failed to provide goods and services necessary to treat pain and provide prompt medical attention which resulted in a fracture for 1 of 27 sampled residents (Resident #239) resulting in HARM (a situation in which the provider's noncompliance resulted in a negative outcome that had compromised the resident's ability to maintain and/or reach his/her hightest practical physical, mental and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care and provision of services). Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum (MDS) data set [DATE] revealed Resident #239 had a Brief Interview for Mental Status score of 11, indicating moderate cognitive impairment; required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene and required total dependence for bathing. Continued review revealed the resident was not steady and only able to stabilize with staff assistance. Further review revealed Resident #239 was at risk for falls and had a fall with major injury since admission. Medical record review of a facility investigation revealed on 3/26/18 at 5:00 AM Resident #239 was found in a room across from her room, sitting on the floor behind a couch. Continued review revealed at 6:30 AM the resident complained of pain to the right thigh. Medical record review of a statement dated 3/26/18 written by Licensed Practical Nurse #6 revealed .(at) approximately 7AM patient was in dining room and complained of pain to right leg (upper) to the therapist when she tried to stand her up. Pain was reported to this writer by the therapist. Endorsed the c/o (complaint of) pain to right leg to incoming nursing supervisor to f/u (fol… | 2020-09-01 |
| 731 | 731 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2018-04-18 | 641 | D | 0 | 1 | 24XE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to accurately assess the use of insulin on the Minimum Data Set (MDS) for 1 of 42 sampled residents (Resident # 50) reviewed. Findings include: Medical record review revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] for Resident #50 revealed the resident did not receive any insulin during the 7 day review period. Interview with Resident #50 on 4/16/18 at 11:27 AM in her room stated she received insulin injections daily. Medical record review of physician's orders [REDACTED]. Medical record review of the Blood Sugar Administration Record for (MONTH) (YEAR) revealed Resident #50 was administered regular and [MEDICATION NAME] as ordered from 2/1/18 - 2/28/18. Interview with Registered Nurse #2 (MDS Coordinator) on 4/18/18 at 9:40 AM in the conference room confirmed the facility failed to accurately assess Resident #50's use of insulin on the Quarterly MDS dated [DATE]. | 2020-09-01 |
| 732 | 732 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2018-04-18 | 655 | G | 0 | 1 | 24XE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to identify interventions on a baseline Care Plan for 1 of 27 sampled residents (Resident #239) reviewed which resulted in a HARM (a situation in which the provider's noncompliance resulted in a negative outcome that had compromised the resident's ability to maintain and/or reach his/her hightest practical physical, mental and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care and provision of services) for the facility's failure to provide fall interventions to keep the Resident safe after identification as 'high' falls risk. Findings include: Review of facility policy Baseline Care Plans dated 11/28/17 revealed .To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission .The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan . Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum (MDS) data set [DATE] revealed Resident #239 had a Brief Interview for Mental Status score of 11, indicating mild cognitive impairment; required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene and required total dependence for bathing. Continued review revealed the resident was not steady and only able to stabilize with staff assistance for moving from a seated to standing position. Further review revealed Resident #239 was at risk for falls and had a fall with major injury since admission. Medical record review of a Morse Fall Scale (an evidence based tool used to provide a quick and simple assessment of a patient's likelihood of falling) dated 3/23/18… | 2020-09-01 |
| 733 | 733 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2018-04-18 | 689 | G | 0 | 1 | 24XE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Physician's Orders, Radiology Report, Nurse's Notes, facility investigation and interview, the facility failed to prevent an accident which resulted in a fracture for 1 of 27 sampled residents (Resident #239) resulting in a HARM. Findings include: Review of facility policy Fall Prevention and Investigation dated 11/28/16 revealed .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls . Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum (MDS) data set [DATE] revealed Resident #239 had a Brief Interview for Mental Status score of 11, indicating moderate cognitive impairment; required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene and required total dependence for bathing. Continued review revealed the resident was not steady and only able to stabilize with staff assistance. Further review revealed Resident #239 was at risk for falls and had a fall with major injury since admission. Medical record review of a facility investigation revealed on 3/26/18 at 5:00 AM Resident #239 was found in a room across from her room, sitting on the floor behind a couch. Continued review revealed at 6:30 AM the resident complained of pain to the right thigh. Review of a facility investigation dated 3/26/18 revealed Resident #239 had a fall resulting in fracture at 5:00 AM and the Medical Director/Attending Physician was notified at 7:30 AM and 8:30AM with no response documented. Review of a Physician's Order dated 3/26/18 at 1449 (2:49PM) revealed a phone order rec… | 2020-09-01 |
| 734 | 734 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2018-04-18 | 697 | G | 0 | 1 | 24XE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide pain management post-fall with a fracture (HARM) after verbal complaints of pain for 1 of 27 sampled residents (Resident #239) reviewed. Findings include: Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum (MDS) data set [DATE] revealed Resident #239 had a Brief Interview for Mental Status score of 11, indicating moderate cognitive impairment. Continued review revealed the resident had vocal complaints of pain during the assessment review period. Further review revealed Resident #239 had a fall with major injury since admission. Medical record review of facility investigation dated 3/26/18 revealed at 5:00 AM Resident #239 was found sitting on the floor behind a couch in a room across the hall from her room. Continued review revealed at 6:30 AM the resident complained of pain to the right thigh to the Physical Therapist (PT). Medical record review of a statement dated 3/26/18 written by Physical Therapist #1 revealed .Brought patient to P.T. (physical therapy) gym to stand in parallel bars. Patient unable to secondary to pain. Patient then told therapist she had fallen. Therapist took patient back to nurse and told nurse of patient's pain . Medical record review of a statement dated 3/26/18 written by Licensed Practical Nurse #6 revealed .(at) approximately 7AM patient was in dining room and complained of pain to right leg (upper) to the therapist when she tried to stand her up. Pain was reported to this writer by the therapist. Endorsed the c/o (complaint of) pain to right leg to incoming nursing supervisor to f/u (follow-up) (with) MD . Review of a facility investigation dated 3/26/18 revealed Resident #239 had a fall resulting in fracture at 5:00 AM and the Medical Director/Attending Physician was notified at 7:30 AM and 8:30 AM with no… | 2020-09-01 |
| 735 | 735 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2018-04-18 | 758 | D | 0 | 1 | 24XE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure as needed (PRN) [MEDICAL CONDITION] medications had a 14 day limitation or prescriber documentation with medical rationale for continuation for 2 of 7 sampled residents (Resident #238 and Resident #239) reviewed. Findings include: Medical record review revealed Resident #238 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Continued review revealed no stop date. Medical record review of (MONTH) (YEAR) - (MONTH) (YEAR) Medication Administration Record [REDACTED]. Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Continued review revealed no stop date. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with the Director of Nursing on 4/18/18 at 6:10 PM in the conference room confirmed the facility failed to ensure PRN [MEDICAL CONDITION] medication had a 14 day limitation or documented rationale for continuation for Resident #238 and Resident #239. | 2020-09-01 |
| 736 | 736 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2018-04-18 | 800 | F | 0 | 1 | 24XE11 | Based on facility policy review, observation and interview the facility failed to serve milk and protein shakes at the appropriate temperature for consumption for 87 residents. Findings include: Review of facility policy Food Temperature and Preparation Service revised 11/28/17 revealed .The danger zone for food temperature is between 41 F (Fahrenheit) and 135 F (Fahrenheit). This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt, and cottage cheese . Observation on 4/16/18 at 12:36 PM in the dietary department revealed milk and protein shakes (which contained milk products) were individually wrapped in plastic glasses placed on metal trays on racks during plating of the food. Continued observation revealed the milk temperature was 42 degrees Fahrenheit and the protein shakes were 44 degrees Fahrenheit. These temperatures were not within the safe range for consumption or distribution. Interview with the Food Service Supervisor on 4/16/18 at 12:40 PM in the dietary department confirmed that the milk and protein shake were not within the appropriate and safe range for consumption. Interview Food Service Supervisor on 4/18/18 at 8:47 AM in his office confirmed the facility failed to serve milk and protein shakes at the appropriate temperature for 87 residents. | 2020-09-01 |
| 737 | 737 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2019-05-02 | 803 | F | 0 | 1 | SHOF11 | Based on review of the resident council minutes, review of the 4 week cycle menu, Review of the POS [REDACTED]. The findings include: Review of the Resident Council Minutes dated 2/27/19 revealed 2 residents stating would like something other than chicken and goulash, meal ticket stated resident did not like pork and that was not true, would like more variety on the menu. Review of the facility 4 week menu cycle revealed the following: On Week 2 a chicken entree was listed for the Sunday evening meal, the Monday mid-day meal, the Tuesday evening meal and for the Saturday evening meal. On Week 3 a chicken entree was listed for the Sunday mid-day and evening meals, therefore chicken was served for 3 consecutive meals, excluding the breakfast meal. A pork entree was listed for the Monday mid-day meal and both the Tuesday mid-day and evening meals. On Week 4 a pasta entree was listed for the Sunday and Monday mid-day meals. A chicken entree was listed for the Tuesday evening meal and the Wednesday mid-day meal. Chicken Fried Steak was listed on the Thursday evening and the Saturday mid-day meals. Review of the POS [REDACTED]. Further observation revealed no therapeutic diet menu and no specific portion identified for each food item served on the menu. Review of the cooks menu for 4/29/19 revealed the mid-day meal matched the mid-day meal on the posted menu. Further observation of the evening meal revealed Pot Roast, Mashed Potatoes, Peas and Carrots were to be served. The cooks menu for the evening meal did not match the posted menu. Observation on 4/29/19 at 11:43 AM in the dietary department of the resident mid-day meal trayline, with the Dietary Supervisor present, revealed Pork in Gravy, Lima Beans, Mashed Potatoes and Carrots were to be served. Further observation revealed pureed foods on the trayline. Continued observation revealed regular textured diets were receiving the pork in gravy, mashed potatoes with gravy and carrots. Continued observation revealed the pureed textured diets received pureed meat with gr… | 2020-09-01 |
| 738 | 738 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2019-05-02 | 804 | D | 0 | 1 | SHOF11 | Based on review of the resident council minutes, review of the resident posted menu, observation and interview, the facility dietary department failed to serve palatable pureed textured meat for 1 of 3 meals observed. The findings include: Review of the Resident Council Minutes dated 2/27/19 revealed 2 residents stating would like something other than chicken and goulash, meal ticket stated resident did not like pork and that was not true, would like more variety on the menu, more salads like potato salad and macaroni salad. Review of the 4/29/19 resident mid-day meal posted menu revealed Marinated Pork Chops and Gravy, Lima Beans, and Coin Carrots. Further observation revealed no therapeutic diet menu and no portion per food item specified on the menu. Observation on 4/29/19 at 11:43 AM in the dietary department, with the Dietary Supervisor present, revealed the resident mid-day meal trayline was in operation. Further observation revealed the trayline included Pork in Gravy, Lima Beans, Mashed Potatoes and Carrots. Further observation revealed pureed foods on the trayline. Continued observation revealed the pureed textured diets received pureed meat with gravy, mashed potatoes with gravy, and pureed carrots. Further observation revealed the 2 surveyors and the Dietary Supervisor tasted all foods on the tray line including the pureed textured foods. The pureed meat tasted like bread and the meat was not able to be determined. Interview with the cook/server on 4/29/19 at 11:57 AM at the dietary department trayline when asked what the meat was in the pureed meat stated .breaded chicken tenders with bread added . When the cook/server was asked why the pureed meat was not pork as listed on the posted and cooks menus, the cook/server stated .a lot of them (residents) don't like pork . Interview with the Dietary Supervisor on 4/29/19 at 11:59 AM in the dietary department when asked how he would describe the taste of the pureed meat confirmed it .tastes like bread . | 2020-09-01 |
| 3326 | 3326 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2019-05-21 | 842 | D | 1 | 0 | T9UH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to maintain accurate medication administration record for 1 of 3 residents (#1) reviewed. The findings include: Review of the facility policy revised 2/2018, Protection of Residents: Reducing the Threat of Abuse and Neglect revealed .Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone .It is the policy of this facility to screen staff (as defined in this policy) for a history of abuse, neglect, exploitation, or misappropriation of resident property in order to prohibit abuse, neglect, and exploitation of resident property .The deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongs or money without the resident's consent. Residents' property includes all residents' possessions, regardless of their apparent value to others since they may hold [MEDICATION NAME]'s value to the resident . Review of the facility policy revised 1/1/13, Inventory of Controlled Substances revealed .The facility should routinely reconcile the number of doses remaining in the packages to the number of remaining doses recorded on the controlled Substances Verification/Shift Count Sheet, to medication administration record . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment Medical record review of the care plan dated 4/26/19 revealed .Resident at risk of pain. Risk factors include: Pancreatitis (inflammation of the pancreas), pancreatic CA (cancer), kidney stones . Medical record review of the Discharge Patient Medication Report dated 4/25/19 revealed .[MEDICATION NAME]/apap ([MEDICATION NAME]) (pain m… | 2020-09-01 |
| 3327 | 3327 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2017-09-08 | 441 | E | 0 | 1 | HBRQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to prevent the potential spread of infection for 2 of 3 (Resident #144 and 157) sampled residents with pressure ulcers that were observed during wound care. The findings included: 1. The facility's Hand Hygiene policy documented, .Handwashing/hand hygiene is generally considered the most important single procedure for preventing nosocomial infections . 2. Medical record review revealed Resident #144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #144's room on 9/7/17 at 2:16 PM, revealed Licensed Practical Nurse (LPN) #1 performed hand hygiene, donned gloves, placed a paper towel barrier on the overbed table, assisted to position Resident #144 onto the Resident's right side, gathered wound care supplies from the cart in the doorway, removed a wound dressing from the coccyx area dated 9/6, which revealed a large shallow open wound approximately 6 centimeters (cm) by 2 cm. LPN #1 cleaned the wound with normal saline, patted the wound dry with gauze, and changed gloves without performing hand hygiene. LPN #1 then applied [MEDICATION NAME] dressing to the wound bed, and covered the wound with a [MEDICATION NAME] dressing. LPN #1 then repositioned Resident #144 to the left side, and removed a dressing from the right hip dated 9/6, revealing an open wound approximately 2 cm in diameter. The wound bed was covered in yellow slough with redness around the edges. LPN #1 changed gloves without performing hand hygiene, went to the treatment cart to retrieve more supplies, then returned to the bedside. LPN #1 then applied Venelex ointment to the wound bed using a gloved finger, and covered with an Allevyn dressing. LPN #1 did not perform hand hygiene between the 2 wound dressing changes, or between glove changes. 4. Medical record review revealed Resident #157 was admitted to the facility o… | 2020-09-01 |
| 3328 | 3328 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2019-09-11 | 758 | D | 0 | 1 | L07511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to provide a duration for the use of a PRN (as needed) [MEDICAL CONDITION] (chemical substance that alters perception, mood, consciousness, cognition or behavior) medication for 1 (#14) of 16 residents reviewed for unnecessary medications. The findings include: Review of facility policy, [MEDICAL CONDITION] Medication Use, revised 11/28/16 revealed .A [MEDICAL CONDITION] drug is any medication that affects brain activities associated with mental processes and behavior .PRN (as needed) orders for [MEDICAL CONDITION] drugs should be limited to 14 days .if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order .PRN orders for anti-psychotic drugs should be limited to 14 days and should not be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication .The facility should not extend the PRN antipsychotic orders beyond 14 days . Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #14's Physician order [REDACTED].[MEDICATION NAME] (an antianxiety medication) 0.5 mg (milligram) 1 tab (tablet) PO (by mouth) BID (twice daily) PRN (as needed) . Medical record review of Resident #14's Pharmacy Consultation Report dated 8/2/19 revealed .(Resident #14) has a PRN order for an anxiolytic, without a stop date: [MEDICATION NAME] 0.5 mg BID PRN ANXIETY .please discontinue PRN [MEDICATION NAME] .if the medication cannot be discontinued at this time, current regulations require that the prescriber document the indication for use, the intended duration of therapy, and the rationale for the extended time period . Interv… | 2020-09-01 |
| 3329 | 3329 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2018-10-09 | 641 | D | 0 | 1 | VITV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess Hospice Services and Bilevel Positive Airway Pressure ([MEDICAL CONDITION]) treatment for 1 of 35 residents (#51) reviewed. The findings include: Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED].admit to .hospice services .[MEDICAL CONDITION] at bedtime . Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed Resident #51 as having no Hospice services or [MEDICAL CONDITION] treatment. Interview with the MDS Coordinator on 10/9/18 at 8:59 AM in her office confirmed the facility did not accurately assess Resident #51 for hospice services and [MEDICAL CONDITION] treatment. | 2020-09-01 |
| 3330 | 3330 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2018-10-09 | 710 | D | 0 | 1 | VITV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to administer medication per the physician order [REDACTED]. The findings include: Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician order [REDACTED]. Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview with the Director of Nursing on 10/9/18 at 10:24 AM in the conference room stated the MAR indicated [REDACTED]. Further interview confirmed the facility failed to follow the physician orders. | 2020-09-01 |
| 3331 | 3331 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2018-10-09 | 812 | E | 0 | 1 | VITV11 | Based on observation and interview, the facility failed to store thawing meat in a manner to prevent contamination in 3 of 6 observations; and failed to maintain dietary equipment in a sanitary manner in 1 of 6 observations. The findings include: Observation on 10/7/18 at 8:55 AM in the dietary department walk-in refrigerator revealed roast beef wrapped in plastic wrap and 1 open case containing 1 vacuum pack ham on a sheet pan and 1 open case of vacuum pack roast turkey breast stored over 2 open cases of vacuum packed scrambled eggs. Further observation revealed 2 plastic bags labeled ham on a sheet pan stored over an open case of fresh eggs with the eggs exposed. Observation on 10/7/18 at 12:11 PM in the dietary department walk-in refrigerator revealed 1 vacuum pack roast turkey breast in an opened case and a vacuum pack ham in an opened case stored on the same sheet pan placed over 2 opened cases of vacuum pack scrambled eggs. Further observation revealed 2 plastic bags labeled turkey and 2 plastic bags labeled ham on a sheet pan placed over the open case of fresh eggs with the eggs exposed. Observation on 10/7/18 at 1:38 PM in the dietary department walk-in refrigerator, with the Dietary Manager present, revealed an open case with 1 vacuum pack turkey roast and a 2nd open case with 1 vacuum packed ham on a sheet pan over 2 cases of vacuum pack scrambled eggs. Further observation revealed a sheet pan with 2 plastic bags labeled turkey placed over the open case of fresh eggs with eggs exposed. Interview with the Dietary Manager on 10/7/18 at 1:38 PM in the dietary department walk-in refrigerator, when asked where the thawing meats were located, the Dietary Manager stated the .thawing meats were on sheet pans . stored over the open cases of fresh eggs and vacuum packed scrambled eggs. Further interview revealed when asked if the thawing location was appropriate the Dietary Manager stated .since the meats were on a pan it was okay . Observation on 10/8/18 at 8:45 AM in the dietary department, with the Dietary Man… | 2020-09-01 |
| 4596 | 4596 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2016-06-22 | 322 | D | 0 | 1 | Z09911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the ENTERAL TUBE MEDICATION ADMINISTRATION provided by the American Society of Consultant Pharmacists, medical record review, observation, and interview, the facility failed to ensure 1 of 1 nurses (Registered Nurse (RN) #1) administered medications by gravity through a percutaneous endoscopic gastrostomy (PEG) tube. The findings included: The ENTERAL TUBE MEDICATION ADMINISTRATION provided by the American Society of Consultant Pharmacists documented, .Remove plunger from the 60 mL (milliliter) syringe and connect syringe to clamped tubing .Pour dissolved/diluted medication in syringe and unclamp tubing, allowing medication to flow by gravity . Medical record review revealed Resident #167 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #167's room on 6/21/16 beginning at 8:14 AM, revealed RN #1 obtained a 60 ml syringe and did not remove the plunger. RN #1 drew up dissolved medication with the 60 ml syringe. RN #1 then connected the syringe to the PEG tube and pushed the medication into the tube. RN #1 did not allow the medication to flow into the tube by gravity. Interview with the Director of Nursing (DON) on 6/22/16 at 2:38 PM, in the DON office, the DON was asked if medications administered through a PEG tube should be allowed to flow by gravity. The DON stated, .by gravity, yes . | 2019-09-01 |
| 4597 | 4597 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2016-06-22 | 372 | D | 0 | 1 | Z09911 | Based on policy review, observation, and interview, the facility failed to ensure garbage and refuse was disposed of properly for 2 of 2 (6/20/16 and 6/21/16) days of the survey. The findings included: 1. The facility's Food and Nutrition Services In-service Training Manual policy documented .Close the dumpster lid . 2. Observations of the dumpster on 6/20/16 at 2:36 PM, and at 6:16 PM, and 6/21/16 at 3:15 PM, revealed the dumpster lids were open. Interview with the Dietary Manager (DM) on 6/22/16 at 11:46 AM, in the conference room, the DM was asked if the dumpster was supposed to be closed. The DM stated, Oh, yes. | 2019-09-01 |
| 4598 | 4598 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2016-06-22 | 431 | D | 0 | 1 | Z09911 | Based on policy review, observation, and interview, it was determined the facility failed to ensure medications were stored properly as evidenced by a medication left unattended at the bedside for 1 of 27 (Resident #12) sampled residents included in the stage 2 review. The findings included: 1. The facility's Self-Administration of Medications policy documented, .The manner of storage prevents access by other residents. Lockable drawers or cabinets are required . 2. Observations in Resident #12's room on 6/20/16 at 4:43 PM, 6/21/16 at 7:40 AM, 9:55 AM, and 3:15 PM, and 6/22/16 at 7:31 AM, revealed a bottle of multi-vitamins sitting on the cabinet unattended. 3. Interview with the Director of Nursing (DON) on 6/22/16 at 10:25 AM, in the conference room, the DON was asked if medications should be stored at the bedside. The DON stated, Quite honestly, no. | 2019-09-01 |
| 4599 | 4599 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2016-06-22 | 441 | D | 0 | 1 | Z09911 | Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 6 (Registered Nurse (RN) #1) nurses did not properly clean a feeding syringe and 1 of 6 (Licensed Practical Nurse (LPN) #1) nurses did not properly clean a nebulizer while administering medications, and an opened package of briefs were stored on the floor in 1 of 74 (Resident #442) resident rooms. The findings included: 1. The facility's Cleaning/Sanitizing, Disinfection, & Sterilization policy documented, .Clean supplies and equipment immediately after use . Observations in Resident #167's room on 6/21/16 beginning at 8:20 AM, revealed RN #1 administered medications through the feeding tube and placed the syringe with the plunger intact into a bag hanging beside the feeding pump. RN #1 did not clean the syringe after administering the medications or before placing it in the bag. Observations in Resident #452's room on 6/21/16 beginning at 5:53 PM, revealed LPN #1 administered a breathing treatment to Resident #452 and placed the nebulizer equipment back in the bag at the bedside. LPN #1 did not clean the nebulizer equipment after performing the breathing treatment or before placing it in the bag. Interview with the DON on 6/22/16 at 2:45 PM, in the DON office, the DON was asked if feeding syringes should be cleaned after administering medications through a feeding tube. The DON stated, Yes, they should clean it. The DON was asked if nebulizer equipment should be cleaned after a breathing treatment is administered. The DON stated, .yes it should be taken apart and rinsed out and allowed to air dry. 2. Observations in Resident #442's room on 6/20/16 at 3:08 PM, and 4:32 PM, and 6/21/16 at 7:50 AM, revealed an opened package of briefs sitting on the floor by the commode in the bathroom. Interview with the Director of Nursing (DON) on 6/22/16 at 10:55 AM, at the 200/300 hall nurses' station, the DON was asked if it was acceptable to store an opened package… | 2019-09-01 |
| 5056 | 5056 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2016-03-10 | 241 | D | 0 | 1 | YFJA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to maintain residents' dignity and respect during dining observations when 1 of 14 staff members (Certified Nursing Assistant (CNA) #1) referred to residents as feeder. The findings included: The facility's RESIDENT SALUTATION policy documented, .Goal: To ensure respect and provide proper salutation in calling residents' names .All residents should be addressed as Mrs., Mr., or Ms. Before their name .Residents who preferred to be called otherwise will be care planned .The facility will not use names like honey, sweetheart, or sweety . Observations in the main dining room on 3/9/16 at 5:05 PM revealed CNA #1 was standing over a table with 4 residents seated. CNA #1 stated, This is the feeders .this is the feeder table .Pick up that tray. This is the feeders .She's a feeder too (pointing to a resident seated at the table) . Interview with CNA#1 at the meal cart outside the main dining room on 3/9/16 at 5:10 PM, CNA #1 stated, .these are the feeders . Interview with the Director of Nursing (DON) on 3/10/16 at 12:35 PM in room [ROOM NUMBER], the DON was asked is it acceptable for staff to address the residents as feeders and the DON stated, No. It's assist. | 2019-05-01 |
| 5057 | 5057 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2016-03-10 | 282 | D | 0 | 1 | YFJA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow care plan interventions for pressure ulcers for 1 of 25 (Resident #31) sampled residents of the 40 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 1/5/16 documented, .PROBLEM .At Risk to Alteration in Skin Integrity . APPROACHES/INTERVENTIONS . Heel protectors to both feet at all times while in bed .PROBLEM .ACTUAL PRESENCE OF SKIN PROBLEM .Pressure Ulcer .Stage .III (3) .SITE: (Right) Gr. (great) toe .APPROACHES/INTERVENTIONS .Provide heel protectors . Observations in Resident #31's room on 3/7/16 at 5:19 PM, revealed Resident #31 lying in bed with a bare foot uncovered and resting on the edge of the mattress. No heel protector was in place. Observations in Resident #31's room on 3/9/16 at 7:30 AM, revealed Resident #31 lying in bed, her right foot was outside the blanket, bare, and resting on edge of mattress. A heel protector was lying on the floor beside the bed. Interview with Licensed Practical Nurse (LPN) #6 on 3/8/16 at 3:40 PM on the 300 hall, LPN #6 was asked whether Resident #31 should be wearing heel protectors. LPN #6 stated, Yes. Interview with the Director of Nursing (DON) on 3/8/16 at 5:30 PM in room [ROOM NUMBER], the DON was asked whether Resident #31 should be wearing heel protectors while in bed. The DON stated, All the time. | 2019-05-01 |
| 5058 | 5058 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2016-03-10 | 314 | D | 0 | 1 | YFJA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide heel protectors as ordered to promote healing and prevention of pressure ulcers for 1 of 3 (Resident #31) sampled residents reviewed of the 4 residents with pressure ulcers. The findings included: The facility's Prevention of Pressure Ulcers policy documented, .General Preventative Measures .Risk Factor - Immobility .When in bed, every attempt should be made to float heels (keep heels off of the bed) .with other devices as recommended by the therapist and prescribed by the physician . Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED].Apply heel protectors to both feet at all times while in bed q (every) shift for protection . The care plan dated 1/5/16 documented, .PROBLEM .At Risk to Alteration in Skin Integrity . APPROACHES/INTERVENTIONS . Heel protectors to both feet at all times while in bed .PROBLEM .ACTUAL PRESENCE OF SKIN PROBLEM .Pressure Ulcer .Stage .III (3) .SITE: (Right) Gr. (great) toe .APPROACHES/INTERVENTIONS .Provide heel protectors . Observations in Resident #31's room on 3/7/16 at 5:19 PM, revealed Resident #31 lying in bed with a bare foot uncovered and resting on the edge of the mattress. No heel protector was in place. Observations in Resident #31's room on 3/9/16 at 7:30 AM, revealed Resident #31 lying in bed, her right foot was outside the blanket, bare, and resting on edge of mattress. A heel protector was lying on the floor beside the bed. Interview with Licensed Practical Nurse (LPN) #6 on 3/8/16 at 3:40 PM on the 300 hall, LPN #6 was asked whether Resident #31 should be wearing heel protectors. LPN #6 stated, Yes. Interview with the Director of Nursing (DON) on 3/8/16 at 5:30 PM in room [ROOM NUMBER], the DON was asked whether Resident #31 should be wearing heel protectors while in bed. The DON stated, All the time. | 2019-05-01 |
| 5059 | 5059 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2016-03-10 | 315 | D | 0 | 1 | YFJA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to perform a bowel and bladder (B & B) training/assessment for 1 of 3 (Resident #78) sampled residents of the 4 residents with a decline in urinary incontinence. The findings included: Medical record review documented Resident #78 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #78 was always continent. The 60-day MDS assessment dated [DATE] documented Resident #78 was frequently incontinent. The quarterly MDS assessment dated [DATE] documented Resident #78 was occasionally incontinent. The care plan dated 9/18/15 and reviewed 12/21/15 documented, .Incontinence Risk- Bowel-Functional .needs assist in transfer (and) toileting needs .on diuretic .Check resident every two hours and assist with toileting as needed . The PROGRESS/REVISIONS notes dated 9/25/15 documented, .Resident (Resident #78) requires extensive assist for toilet use. She (Resident #78) has [DIAGNOSES REDACTED]. Staff to ensure that toileting needs are being met and anticipate needs . The PROGRESS/REVISIONS notes dated 12/21/15 documented, .Occasionally incontinent c (with) bladder @ (at) this time . The Continence Evaluation form dated 9/18/15 documented Resident #78 with functional incontinence and treatment options of bedside commode, personal hygiene, and incontinent product. The Bowel and Bladder assessment dated [DATE] documented a Resident #78 with score of 8, which indicated a candidate for Bowel and Bladder (B & B) training. There was no documentation of B & B training in the medical record. Interview with MDS Coordinator #1 on 3/10/16 at 1:11 PM in the nurses' station, he was asked if a Bowel and Bladder Assessment is performed, and indicates a resident is a candidate for B & B training, then what would be done. He stated, We should do an assessment to determine a pattern .when wet and dry and if would qual… | 2019-05-01 |
| 5060 | 5060 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2016-03-10 | 322 | D | 0 | 1 | YFJA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure physician orders [REDACTED].#31) sampled residents reviewed with a Percutaneous Endoscopic Gastrostomy (PEG) tube. The findings included: The facility's Care of the Resident with a Gastric Tube; Enteral Nutrition and Medication Administration policy documented, .Enteral feedings will be administered to the Resident as ordered by the Physician/NP (Nurse Practitioner) . Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Enteral Feed Order every shift Diet Iso Source 1.5 x 45 ml (milliliters)/ (per) hr (hour) x (times) 20 hours/day (off 9 am-PM) . Review of the dietary notes dated 3/3/16 documented, .[MEDICATION NAME] 1.5 .45 ml/hr . Observations in Resident #31's room on 03/07/16 at 3:15 PM revealed the resident lying in bed with [MEDICATION NAME] 1.5 hanging and the infusion was off at this time. Observations in Resident #31's room on 03/07/16 at 5:19 PM revealed Resident #31 lying in bed with the tube feeding off. Observations in Resident #31's room on 3/9/16 at 6:45 AM revealed the resident lying in bed with [MEDICATION NAME] 1.5 infusing at 40 cc/hr. Interview with Licensed Practical Nurse (LPN) #7 on 3/9/16 at 7:00 AM in front of Resident #31's room, LPN #7 was asked when Resident #31 receives her tube feedings. LPN #1 stated, It runs all night. We manually turn it off at 9 o'clock, and it comes back on at 1 o'clock. LPN #7 was asked what was the current rate of the tube feeding. LPN #7 stated, It's 40 cc (ml)/hr. LPN #7 was asked what should the rate be. LPN #7 walked to the nurses' station and checked the orders. LPN #7 stated, It's supposed to be 45. I'm going to go put it where it's supposed to be. | 2019-05-01 |
| 5061 | 5061 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2016-03-10 | 332 | D | 0 | 1 | YFJA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 5 (Licensed Practical Nurse (LPN) #2 and 3) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 28 opportunities, resulting in a medication error rate of 7%. The findings included: 1. The facility's Medication Administration policy documented, .Medications must be administered in accordance with the orders, including any required time frame . 2. Medical record review revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders dated 2/25/16 documented, .[MEDICATION NAME]-[MEDICATION NAME] Tablet 5-500 MG (milligram) Give 1 tablet via (by) PEG- (Percutaneous Endoscopic Gastrostomy) Tube four times a day for Pain . Observations in Resident #59's room on 3/8/16 at 5:13 PM, revealed LPN #2 administered [MEDICATION NAME] APAP 5-325 mg to Resident #59 via Peg tube. The administration of [MEDICATION NAME] APAP 5-325, instead of 5-500 mg, resulted in medication error #1. Interview with the Director of Nursing (DON) on 3/9/16 at 9:50 AM at the 400 hall medication cart, the DON was asked about the order for [MEDICATION NAME] APAP for Resident #59. The DON stated, .yes the order says .dose 5-500 .the medication label in the cart says 5-325 .yes, she got the 5-325 . 3. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders did not document an order for [REDACTED].>Observations in Resident #3's room on 3/10/16 at 9:45 AM, revealed LPN #3 administered Zinc Sulfate 220 mg to the resident by mouth. The administration of Zinc Sulfate 220 mg resulted in medication error #2. Interview with Registered Nurse (RN) #1 on 3/10/16 at 12:56 PM at the main nursing station, RN #1 was asked if there was an order for [REDACTED].#1 stated, .no that order was stopp… | 2019-05-01 |
| 5062 | 5062 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2016-03-10 | 431 | D | 0 | 1 | YFJA11 | Based on observation and interview, the facility failed to ensure medications were properly stored and medications were not expired in 3 of 10 (100 hall medication cart, crash cart number #1, and crash cart #2) medication storage areas. The findings included: 1. Observations in the medication room on 3/9/16 at 11:18 AM, revealed the following: a. a loose tablet lying in a miscellaneous container in the top drawer of the 100 hall medication cart. b. a loose tablet in a medication compartment in the second drawer of the 100 hall medication cart. Interview with Licensed Practical Nurse (LPN) #1 on 3/9/16 at 11:22 AM in the medication room, LPN #1 was asked if there were loose tablets in the 100 hall medication cart. LPN #1 stated, Yes . LPN #1 was asked if tablets should be loose and out of their original containers in the medication carts. LPN #1 stated, .no .they get loose in there .I'm throwing them away . 2. Observations at crash cart #1, near the 300 hall, on 3/10/16 at 4:50 PM, revealed the following: a. a 1000 milliliter (ml) bag of 1/2 Normal Saline with an expiration date of November, (YEAR). b. a 1000 ml bag of 5 percent (%) Dextrose in Normal Saline with an expiration date of November, (YEAR). Interview with Registered Nurse (RN) #2 on 3/10/16 at 4:51 PM at crash cart #1, RN #2 was asked if the bag of 1/2 Normal Saline and the bag of 5% Dextrose in Normal Saline were expired. RN #2 stated, Yes they are .I need to get rid of those . 3. Observations at crash cart #2, near the 600 hall, on 3/10/16 at 4:54 PM, revealed the following: a. a 1000 ml bag of 5% Dextrose with an expiration date of January, (YEAR). b. a container of sterile water for inhalation with an expiration date of October, 2014. Interview with RN #2 on 3/10/16 at 4:57 PM at crash cart #2, RN #2 was asked if the bag of 5% Dextrose and the container of sterile water for inhalation were expired. RN #2 stated, Yes .shouldn't be in there .and I need to get those replaced . Interview with the Director of Nursing (DON) on 3/10/16 at 3:52 PM in the D… | 2019-05-01 |
| 5063 | 5063 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2016-03-10 | 441 | D | 0 | 1 | YFJA11 | Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained by 2 of 5 (Licensed Practical Nurse (LPN) #1 and 4) nurses administering medications. The findings included: 1. The facility's Handwashing/Hand Hygiene policy documented, .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections .Before and after .fingerstick blood sampling .after removing personal protective equipment (gloves) . 2. The facility's Infection Control Standard Precautions policy documented, .Wash hands after touching blood .Wash hands immediately after gloves are removed .Change gloves between tasks and procedures on the same resident . 3. Observations in Resident #90's room on 3/9/16 beginning at 11:00 AM, revealed Licensed Practical Nurse (LPN) #1 donned gloves, stuck Resident #90's finger with a lancet, obtained a drop of blood for blood glucose monitoring, was unable to get a reading on the monitor, obtained another test strip from the clean supply tray, stuck Resident #90's finger with a lancet, and obtained a second drop of blood for blood glucose monitoring. LPN #1 did not remove her gloves, wash her hands and apply a different pair of gloves between the first and second sticks to obtain blood. Interview with the Director of Nursing (DON) on 3/10/16 at 3:39 PM, in the DON office, the DON was asked what a nurse should do if she dons gloves and sticks a resident to check a blood sugar and has to repeat the test on the same resident. The DON stated, They should remove the old gloves, wash hands and put on new gloves. The DON was asked if the nurse could continue wearing the same pair of gloves for 2 blood glucose sticks on the same resident. The DON stated, Absolutely not. 3. Observations in Resident #107's room on 3/9/16 beginning at 5:26 PM, revealed LPN #4 administered medications to Resident #107, went to the sink, turned on the water and washed her hands with soap, rinsed her hands, turned … | 2019-05-01 |
| 6123 | 6123 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2015-05-13 | 280 | D | 0 | 1 | 2SN011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to revise the comprehensive care plan related to [MEDICAL CONDITION] medications for 1 of 8 (Resident #83) sampled residents of the 35 residents included in the stage 2 review. The findings included: The Facility's [MEDICAL CONDITION] Medication Administration Mental Health Referral Consultation policy documented, .include anti-psychotic, anti-depressant, anti-anxiety, and sedative/hypnotics . Behavior Monitoring Records will be completed by each nurse administering the medication . Medical record review revealed Resident #83 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/22/15 documented Resident #83 received Antipsychotic, Antianxiety, Antidepressant, Antibiotic and Diuretic medications. The care plan dated 4/29/15 did not address the use of antipsychotic medications. Interview with the Interim Director of Nursing (DON) on 5/13/15 at 2:10 PM, in the Administrator's office, when asked would you expect care plan to address antipsychotic medications. The interim DON stated, I would expect them to address [MEDICAL CONDITION] medications. | 2018-10-01 |
| 6124 | 6124 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2015-05-13 | 282 | D | 0 | 1 | 2SN011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to follow the care plan interventions for adverse effect and behavior monitoring for 1 of 8 (Resident #70) sampled residents of the 35 residents included in the stage 2 review. The findings included: The Facility's [MEDICAL CONDITION] Medication Administration Mental Health Referral Consultation policy documented, .include anti-psychotic, anti-depressant, anti-anxiety, and sedative/hypnotics . Behavior Monitoring Records will be completed by each nurse administering the medication . Medical record review revealed Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] (antianxiety) 1mg (milligram) TID (three times day) @ (at) 6 A (morning) , 2 P (evening) + (and) 9 pm . The admission Minimum Data Set (MDS) for Resident #70 with an Assessment Reference Date (ARD) of 4/17/15 documented the medications used in last 7 days were Antidepressant used 7 out of 7 days and Antianxiety used 5 out of 7 days. The care plan dated 4/21/15 documented, .Monitor for adverse effects including but not limited to drowsiness, day-time sedation confusion, nausea, vomiting, anxiety, orthostatic [MEDICAL CONDITION] . Monitor for change in behavior, document . Interview with Registered Nurse (RN) #3 on 5/13/15 at 10:45 AM, in the conference room, when asked about the behavior monitoring sheet for Resident #70. RN #3 stated, I can't find one (behavior sheet) . should be one . Interview with Licensed Practical Nurse (LPN) #1 on 5/13/15 10:22 AM, when asked about the behavior monitoring sheet for Resident #70. LPN #1 stated, I can't find one. | 2018-10-01 |
| 6125 | 6125 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2015-05-13 | 325 | D | 0 | 1 | 2SN011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to follow the physician's order for restorative dining for 1 of 4 (Resident #268) sampled residents reviewed for nutrition of the 35 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #268 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician order dated 4/8/15 documented, .ST (Speech Therapy) to refer to restorative dining . Review of the admission Minimum (MDS) data set [DATE] documented Resident #268 required extensive assistance with eating. A nursing rehabilitation restorative care weekly summary dated 4/30/15 documented, .will d/c (discontinue) from program . A medical progress note dated 5/10/15 documented, .Chief Complaint . wt (weight) loss . Treatment Plan . Restorative Dining . The facility was unable to provide a physician's order to discontinue the restorative dining. Observations in Resident #268's room on 5/13/15 at 11:34 AM, revealed Resident #268 eating lunch in her room being assisted by Certified Nursing Assistant #1. Interview with Restorative Tech (RT) #1 on 5/13/15 at 10:41 AM on the 200 hall, RT #1 was asked if Resident #268 was receiving restorative dining services. RT #1 stated, Not right now, she use to be. Interview with Licensed Practical Nurse #1 on 5/13/15 at 11:12 AM, in the conference room confirmed that a physician's order was needed to discontinue restorative dining services. | 2018-10-01 |
| 6126 | 6126 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2015-05-13 | 329 | D | 0 | 1 | 2SN011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to provide behavior monitoring for antidepressant and antipsychotic medications for 2 of 5 (Residents #70 and 83) sampled residents reviewed for unnecessary medication use of the 35 residents included in the stage 2 review. The findings included: 1. The facility's [MEDICAL CONDITION] Medication Administration Mental Health Referral Consultation policy documented, .Behavior Monitoring Records will be completed by each nurse administering the medication . The facility's Behavior Management policy documented, Behavior management includes assessing behavior patterns that interfere with the resident's functional capacity and ensuring that these patterns are reduced or eliminated to maximize the resident's dignity, independence, and self-determination . 2. Medical record review revealed Resident #70 was admitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] (antianxiety) 1mg (milligram) TID (three times day) @ (at) 6 A (morning), 2 P (evening) + (and) 9 pm . The admission Minimum Data Set (MDS) for Resident #70 with an Assessment Reference Date (ARD) of 4/17/15 documented medications used in last 7 days were Antidepressant used 7 out of 7 days and Antianxiety used 5 out of 7 days. Interview with Registered Nurse (RN) #3 on 5/13/15 at 10:45 AM, in the conference room, when asked about the behavior monitoring sheet for Resident #70. The RN #3 stated, I can't find one (behavior sheet) . should be one . Interview with Licensed Practical Nurse (LPN) #1 on 5/13/15 10:22 AM, when asked about behavior monitoring for Resident #70. LPN #1 stated, I can't find one. 3. Medical record review revealed Resident #83 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The admission MDS with ARD 4/22/15 documented Resident #83 received Antipsychotic, Antianxiety, Antidepressant, Antibiotic and Diuretic medications… | 2018-10-01 |
| 6127 | 6127 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2015-05-13 | 441 | E | 0 | 1 | 2SN011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, the facility failed to ensure practices were implemented to prevent the potential spread of infection as evidenced by failure to maintain contact isolation precautions when no sign was placed on the doors to indicate the residents were in contact isolation for 2 of 3 (Residents #48 and 439) sampled residents reviewed for infection control of the 35 residents included in the stage 2 review. The findings included: 1. The facility's Transmission-based Precautions and Isolation Procedures policy documented, .Type of Isolation Precaution . Contact Precautions . Precaution Requirements . Stop . sign on door . Diseases Requiring Precautions . VRE ([MEDICATION NAME]-Resistant [MEDICATION NAME]) .[DIAGNOSES REDACTED] (Clostridium Difficile) . 2. Medical record review revealed Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's telephone order dated 5/13/15 documented, .stool specimen for[DIAGNOSES REDACTED] . Isolation precautions pending Results . Observations on the 300 hall on 5/13/15 at 1:45 PM, revealed no stop sign on the door of Resident #48's room. Interview with Licensed Practical Nurse (LPN) #2 on 5/13/15 at 1:50 PM, on the 300 hall, when asked why Resident #48 was in isolation. LPN #2 stated, Had loose, foul-smelling stool and upset stomach. We put them in isolation as a precautionary measure until the culture comes back. LPN #2 was asked what staff would need to do before entering the room. LPN #2 stated, For ADL (activities of daily living) care, we have to put on the gown and gloves. LPN #2 was asked what visitors would need to do before entering the room. LPN #2 stated, They would have to do the same, and we tell them not to use the toilet. LPN #2 was asked how a visitor would know to do these things. LPN #2 stated, Let me get a sticker. 3. Medical record review revealed Resident #439 was admitted on [DATE] with [DIAGNOSES … | 2018-10-01 |
| 6648 | 6648 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2015-02-11 | 156 | E | 0 | 1 | XIH911 | Based on review of notices of medicare non-coverage forms and interview, the facility failed to provide the appropriate liability and appeal notices to 2 of 3 (Resident #71 and 134) sampled residents. The findings included: 1. Review of the Notice of Medicare Non-Coverage form for Resident #71 documented a termination date of 9/5/14 and was signed by Resident #71's Responsible Party (RP) on 8/25/14. 2. Review of the Notice of Medicare Non-Coverage form for Resident #134 documented a termination date of 10/10/14 and was signed by Resident #134's RP on 8/26/14. 3. Interview with the admission's coordinator on 2/5/15 at 3:00 PM, outside the business office, the admission's coordinator was asked when she gets the Notice of Medicare non-Coverage form signed. The admission's coordinator stated, Sometimes I get them to sign them on admission because there are some families that don't come back for any of the care plan meetings. Sometimes I get them signed at the discharge planning meetings . it just depends on the family and the situation . that's why some of them are signed way in advance . I don't want to not ever have this signed . Interview with the admission's coordinator on 2/5/15 at 3:25 PM, in the 400 hallway, the admission's coordinator was asked if she would change the termination date on the Notice of Medicare non-Coverage if the resident's termination date changed. The admission's coordinator stated, No, I don't put the date on it until the discharge planning meeting is completed. The admission's coordinator was then asked if she had the responsible party sign the Notice of Medicare non-Coverage without having a termination date on it. The admission's coordinator stated, Yes. | 2018-05-01 |
| 6649 | 6649 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2015-02-11 | 224 | G | 0 | 1 | XIH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to prevent neglect when staff failed to follow up on dental orders and failed to notify the attending physician of a dental procedure while the resident was on anticoagulation medications; and failed to follow the facility's [MEDICATION NAME] therapy protocol for 1 of 4 (Resident #155) sampled residents reviewed with anticoagulation medication and dental procedures. The facility neglected to notify the physician of a dentist's desire to hold [MEDICATION NAME] for a dental procedure and the facility failed to follow the facility's [MEDICATION NAME] protocol when the physician was not contacted about [MEDICATION NAME] time and international normalized ratio (PT/INR) levels when the resident's [MEDICATION NAME] dose was increased which resulted in actual harm when Resident #155 was hospitalized due to bleeding following tooth extraction. The findings included: Review of the facility's policy entitled [MEDICATION NAME] Protocol effective date 6/1/10 documented, .8. The physician will be informed when residents are taking the following medications while on [MEDICATION NAME] . [MEDICATION NAME]. These medications have the potential to significantly increase the PT/INR ([MEDICATION NAME] time - how quickly blood clots - normal range of 10 to (-) 13) INR - normal range 0.8 - 3.50) value while taking [MEDICATION NAME]. The physician will be encouraged to order a PT/INR every other day while taking one of these meds (medications) with [MEDICATION NAME] due to potential for significant increase in INR and risk for bleeding . Medical record review revealed Resident #155 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nurses notes dated 12/6/13, documented the resident developed a [MEDICAL CONDITION] of the right thigh and was started on [MEDICATION NAME] (blood thinner) 7.5 milligrams (mg) daily. The resident had received [MEDICATION NAME] with P… | 2018-05-01 |
| 6650 | 6650 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2015-02-11 | 225 | G | 0 | 1 | XIH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of investigations, review of accident/incident reports, medical record review and interview, the facility failed to thoroughly investigate and report incidents with injuries of unknown origin for 2 of 22 (Residents #149 and 35) sampled residents reviewed for accidents of the 57 residents included in the stage 2 review. The facility failed to report injures of unknown origin to the state survey and certification agency. The facility failed to thoroughly investigate wandering and injuries of unknown origin resulted in actual harm when Resident #149 sustained a laceration and fractured ribs. The findings included: 1. Review of the facility's Abuse, reporting policy dated 6/1/12 documented, .Should a suspected violation or or substantiated incident . injuries of an unknown source . be reported, the facility administrator, or his/her designee, will promptly notify the following persons or agencies of such incident: The State licensing/certification agency responsible for surveying/licensing the facility . Notification to the above agencies will be made as soon as it has been substantiated within 5 working days of the occurrence of such incident . 2. Medical record review revealed Resident #149 was admitted to the facility on [DATE], with readmitted s of 4/16/14 and 9/26/14 with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 8, indicating Resident #149 had moderate cognitive impairment; resident required extensive assistance of one person for dressing, hygiene, locomotion and extensive assistance of two people for transfers. Resident #149's assistive devices used were a wheelchair and a walker. Review of nurses notes dated 3/10/14 at 7:50 PM documented, .resident continue to wander throughout facility and through exit doors . noted . at facility exit fence . attempting to climb . cut . left hand, 3rd finger . Review of nur… | 2018-05-01 |
| 6651 | 6651 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2015-02-11 | 274 | D | 0 | 1 | XIH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of an incident/accident report and interview, the facility failed to complete a significant change Minimum Data Set (MDS) assessment for 2 of 6 (Residents #25 and 128) sampled residents with a significant change of the 57 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE], documented Resident #25 required limited one person assistance for bed mobility, transfer, walk in room and corridor, toilet use, personal hygiene and the resident had no falls since admission, readmission nor prior assessment. Review of a nurses note dated 4/26/14, documented Resident #25 was .noted on the floor outside the main Dining Room laying on right side walker beside (resident), noted with skin tear to left shin . C/O (complained of) L (left) knee + (and) L shoulder pain . Review of a nurses note dated 5/15/14 at 8:30 AM, documented Resident #25 .fell . Right arm redness upper from elbow to armpit . x-ray ordered . A nurse note dated 5/15/14 at 7:00 PM documented, .Resident sitting on floor beside bed . Review of the x-ray report dated 5/15/14 of the right humerus, right hip documented no fractures or dislocation. Review of the facility incident/accident report for 5/15/14 at 7:00 PM documented, .the bed alarm was sounding . Resident found sitting on (resident's) bottom next to bed . Review of a nurses note dated 5/16/14 documented, .3 p.m., late entry. Resident continues to complain of pain after fall. Pain @ (at) L (left) & (and) R (right) hip bilaterally, repositioning back to bed relieved pain temporarily . orders received to transport to hospital . Review of a nurses note dated 5/16/14 at 8:30 through (-) 8:45 PM documented, .Report given from (named hospital) in reference to resident's x-ray of hip done found contusion, did head CT (compute… | 2018-05-01 |
| 6652 | 6652 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2015-02-11 | 278 | D | 0 | 1 | XIH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to accurately assess residents for falls and/or behaviors for 5 of 45 (Residents #9, 25, 149, 150 and 151) sampled residents of the 57 residents in the stage 2 review. The findings included: 1. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) was 2, indicating the resident was severely cognitively impaired. The resident required extensive assistance with Activities of Daily Living (ADL) requiring assistance from one person. The resident required assistance from 2 people for transfers. Review of the Morse fall screening scored the resident as 75 which indicated the resident was a high risk for falls and had a history of [REDACTED]. Review of nurses notes documented the following: a. 3/20/14 at (1:00 PM) - .refused to lay down after lunch . b. 4/2/14 at (1:00 PM) - .refused to lay down after lunch . c. 4/25/14 at 11:00 PM - .extremely restless . d. 5/20/14 (untimed) - .increased confusion/agitation . e. 8 /23/14 at 1:26 AM - .extremely agitated at this time-attempting to get oob (out of bed) s (without) assist . f. 8/30/14 at 12:48 AM - .increased agitation-attempting to remove wedge and get oob . g. 8/31/14 at 1:26 AM - .resident up in WC (wheelchair) r/t (related to) increased agitation . Review of the 24 hour communication endorsement sheets documented the following: a. 6/24/14 11PM - (to) 7AM shift - .up in WC 2(secondary) to coming out of bed . b. 6/27/14 11PM-7AM shift - .restless up in WC . Review of the weekly summary nurses notes documented the following: a. 5/31 through (-) 6/6/14 - .verbally abusive . b. 6/2-6/27/14 - .verbally abusive . c. 10/4-10/10/14 - .climbs oob . d. 11/1-11/7/14 - attempts to get oob s assistance . Review of the social service progress notes dated 4/14/14 d… | 2018-05-01 |
| 6653 | 6653 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2015-02-11 | 280 | G | 0 | 1 | XIH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of incident/accident reports, review of incident investigations, medical record review and interview, the facility failed to revise the care plan to reflect the current status related to risk of falls, fall prevention, behaviors, incontinence with bowel and bladder training and/or vision for 10 of 45 (Residents #149, 9, 25, 57, 61, 113, 114, 117, 150 and 151) sampled residents of the 57 residents in the stage 2 review. The facility's failure to revise the care plan after falls resulted in actual harm when Resident #149 sustained a laceration and abrasion and Resident #9 sustained a contusion to the right hip and a sprained right elbow. The findings included: 1. Review of the facility's care plan policy, with the effective date of 9/1/11, documented An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . Care plans are revised as changes in the resident's condition dictate . 2. Medical record review revealed Resident #149 was admitted to the facility on [DATE] and readmitted on [DATE] and 9/26/14 with [DIAGNOSES REDACTED]. Resident #149 was discharged from the facility on 10/1/14. Review of an admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment; resident required extensive assistance of one person for dressing, hygiene, locomotion; and extensive assistance of two people for transfers, and assistive devices used were a wheelchair and walker. Review of the January 2014 physician orders [REDACTED].apply PSA (personal safety alarm) to bed & (and) wheelchair . monitor resident with wanderguard for risk of elopement q (every) shift . Review of an incident/accident report dated 3/8/14 at 5:10 PM documented, .Type of Incident . Found on the floor . witnessed . Location . at front-p… | 2018-05-01 |
| 6654 | 6654 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2015-02-11 | 282 | D | 0 | 1 | XIH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to follow the care plan to implement incontinence care to prevent future falls for 1 of 57 (Resident #153) sampled residents of the 57 residents included in the stage 2. The findings included: 1. Medical record review revealed Resident #153 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] documented, Resident #153 had short and long term memory impairment, severely impaired decision making skills, required extensive two person assistance for bed mobility, transfer and toileting. Review of Resident #153's care plan initiated 4/8/14 documented the following: a. Fall Risk . related to Unsteady Gait, Cognitive Deficit, Poor Safety Awareness, Weakness, Impaired Mobility . As Evidenced By . History of Falls and Fractures . Unable to Transfer w/o (without) assistance . The approaches included .Keep call light and personal items within easy reach, Remind resident to call for assistance . b. .Incontinent functionally for bowel and bladder related to Inability to communicate needs, Cognitive deficit, Impaired mobility . The approaches included .Observe pattern incontinence, and initiate toileting schedule or prompted voiding, if indicated, Check resident every two hours and assist toileting as needed, provide urinal/bedpan/beside commode, Provide pericare after each incontinent episode, Keep call light within reach, and remind resident to call for assistance . Review of Resident #153's nurses notes documented the following: a. 4/20/14 at 9:45 AM - Resident found on floor on left side in hallway . was in wheelchair and fell out . b. 4/21/14 at 3:30 PM - .was unable to make needs known at times . incontinent Bowel and Bladder (B&B) . Call light within reach . c. 4/26/14 at 9:30 PM - .CNT (Certified Nursing Technician) notified this nurse . resident was on the floor. Upo… | 2018-05-01 |
| 6655 | 6655 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2015-02-11 | 309 | G | 0 | 1 | XIH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, the facility staff failed to follow up on dental orders and failed to notify the attending physician of a dental procedure while the resident was on anticoagulation medications; and failed to follow the facility's [MEDICATION NAME] therapy protocol for 1 of 4 (Resident #155) sampled residents reviewed with anticoagulation medication and dental procedures of the 57 residents included in the stage 2 review. The facility failed to notify the physician of a dentist's desire to hold [MEDICATION NAME] for a dental procedure and the facility failed to follow the facility's [MEDICATION NAME] protocol when the physician was not contacted about [MEDICATION NAME] time and international normalized ratio (PT/INR) levels when the resident's [MEDICATION NAME] dose was increased which resulted in actual harm when Resident #155 was hospitalized due to bleeding following tooth extraction. The facility failed to ensure 1 of 4 (Nurse #19) nurses followed the facility's policy for [MEDICATION NAME] drug delivery system application by failing to clean the site of the old [MEDICATION NAME]. The findings included: 1. Review of the facility's policy entitled [MEDICATION NAME] Protocol effective date 6/1/10 documented, .8. The physician will be informed when residents are taking the following medications while on [MEDICATION NAME] . [MEDICATION NAME]. These medications have the potential to significantly increase the PT/INR ([MEDICATION NAME] time - how quickly blood clots - normal range of 10 to (-) 13) INR - normal range 0.8 - 3.50) value while taking [MEDICATION NAME]. The physician will be encouraged to order a PT/INR every other day while taking one of these meds (medications) with [MEDICATION NAME] due to potential for significant increase in INR and risk for bleeding . Medical record review revealed Resident #155 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of … | 2018-05-01 |
| 6656 | 6656 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2015-02-11 | 315 | E | 0 | 1 | XIH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of incident investigations, review of an in-service, medical record review and interview, the facility failed to provide services to improve normal bladder function to the extent possible by not implementing a bowel and bladder (B&B) training program and failed to implement incontinence care to prevent future falls for 2 of 4 (Residents #25 and 153) sampled residents with incontinence of the 57 residents included in the stage 2 review. The findings included: 1. Review of the facility's B&B training program, with the effective date of 10/1/10 documented, All residents who have incontinence of bowel and bladder shall be assessed to determine if a restorative bowel and bladder program is an appropriate intervention. The Bowel and bladder retraining . is a program that is considered if a resident scores a 9 or below on the bowel and bladder assessment. A three-day assessment is initiated to determine bowel and bladder habits . Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] documented Resident #25 had short and long term memory impairment, moderately impaired decision making skills, and was occasionally incontinent of B&B with no toileting program. Review of the care plan initiated 8/27/13, and updated on 11/29/13, 2/25/14 and 5/25/14 documented Resident #25 was .At risk incontinence bowel and bladder related to cognitive deficit, impaired mobility . The approaches included provide pericare every shift and as needed, keep call light within reach, and remind resident to call for assistance, monitor for signs and symptoms of urinary tract infection . There were no revisions to the care plan since 8/27/13. Review of the B&B assessment dated [DATE] documented Resident #25 had a score of 9, indicating Resident #25 was a candidate for B&B training. Review of a nurses note dated 5/31/14, documented Resident #… | 2018-05-01 |
| 6657 | 6657 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2015-02-11 | 319 | G | 0 | 1 | XIH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of incident/accident investigations, medical record review and interview, the facility failed to identify behaviors of climbing out of bed, implement pertinent interventions and identify the cause of the behaviors for 1 of 5 (Resident #9) sampled residents of the 57 residents in the stage 2 review. The facility failed to identify causes of behaviors and implement appropriate interventions for behaviors resulted in actual harm when Resident #9 fell sustaining a contusion to the right hip and a sprained right elbow. The findings included: 1. Review of the facility's policy titled Behavior Management and assessment dated [DATE] documented, .problematic behavior will be identified and managed appropriately . the staff will identify, document and inform the physician . about an individual's mental status, behavior, and cognition . The staff will identify pertinent interventions, other than medications, for the nature and cause of the individual's problematic behavior . an individualized Plan of Care will be developed . to reflect . resident's condition . Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was severely cognitively impaired and unable to complete the interview. The behavior section of the MDS documented no behavioral symptoms or rejection of care were exhibited by Resident #9. The resident required extensive assistance with Activities of Daily Living (ADL) with assistance needed by 1 person and transfers required assistance from 2 people. Review of the annual MDS dated [DATE] documented no behavioral symptoms were exhibited by Resident #9. Review of Resident #9's nurses notes documented the following: a. 1/5/14 7AM-3PM shift - .call light is within reach but d/t (due to) confusion unable to use . … | 2018-05-01 |
| 6658 | 6658 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2015-02-11 | 323 | G | 0 | 1 | XIH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, review of in-service record, observation and interview, the facility failed to provide supervision to prevent falls and failed to investigate falls per the facility's policy for 10 of 22 (Residents #35, 149, 9, 16, 25, 57, 113, 129, 150, 151 and 153) sampled residents of the 57 residents included in the stage 2 review. Three (3) of the 22 residents sustained harm following a fall or an elopement. The facility failed ensure a safety device was in place and operational to prevent falls resulted in actual harm when Resident #35 fell sustaining a hip fracture. The facility failed to supervise a resident for elopement and falls risk caused actual harm when Resident #149 cut a finger and sustained ribs fractures of an unknown origin. The facility failed to provide supervision, thoroughly investigate falls or ensure a fall mat was in place resulted in actual harm when Resident #9 sustained a hip contusion and a sprained elbow. The findings included: 1. Review of the facility's Elopement/ Wandering policy dated 2/1/09 documented, .will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering . Review of the facility's accidents/incidents investigations policy, revision date 6/1/12 documented, .any accident/incident that results in an injury . falls . must be reported to the immediate supervisor . an investigation of the accident/incident will be made by the designated staff person . Review of the facility's fall protocol dated 4/22/10 documented, .Interdisciplinary Team (IDT) Fall Assessment to begin immediately . In-Service all personnel involved . Alter the Care Plan accordingly . Document in . Licensed Progress Notes x (times) 72 (hours) . Occurrence of another fall require further assessment and action immediately with documentation of the assessment as well as the action . If the Fall Assessment score is > (greater than) 10 place a Sunflower Sign on the door . … | 2018-05-01 |
| 6659 | 6659 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2015-02-11 | 356 | D | 0 | 1 | XIH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of assignment sheet, observation and interview, the facility failed to accurately post nursing staff directly responsible for resident care for 2 of 11 (1/12/15 and 1/17/15) days. The findings included: 1. Review of the facility's Posting Direct Care Daily Staffing Numbers policy dated 6/1/12, documented Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents . The Policy Interpretation and Implementation documented .Directly responsible for resident care means individuals are responsible for resident's total care or some aspect of the resident's care including, but not limited to, assisting with activities of daily living . performing gastrointestinal feeds, giving medications, supervising care given by the CNA's (Certified Nurse Assistant), and performing nursing assessments to admit residents or notify physicians of changes of condition . 2. Observations on Monday, 1/12/15 at 7:51 AM, on the 500 hall revealed the daily staff posting was dated Friday, 1/9/15 and posted on a bulletin board. Observations on 1/12/15 at 9:00 AM, revealed the staffing for the first shift (6:30 AM to 2:30 PM) was 7 Registered Nurse (RN), 6 Licensed Practical Nurse (LPN) and 13 CNAs. Interview with Nurse #11 on 1/12/15 at 8:15 AM at the nurses station, Nurse #11 confirmed the daily staff posting on the bulletin board was dated 1/9/15. Interview with the Administrator (ADM) and the Assistant Administrator (AADM) on 1/12/15 at 11:05 AM in the Administrator's office, the ADM and AADM confirmed the daily staff posting was inaccurate and they had included all RN's and LPN's in the building. The ADM and the AADM confirmed the accurate on-site direct care staffing for the 1st shift was 3 RNs, 4 LPNs and 10 CNAs. 3. Observations on Saturday, 1/17/15 at 4:10 PM, of the daily staff posting on the main hall outside the administrative office and the 500 hall, rev… | 2018-05-01 |
| 6660 | 6660 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2015-02-11 | 411 | D | 0 | 1 | XIH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to schedule a dental appointment for tooth extraction in a timely manner to meet the needs of 1 of 4 (Resident #155) sampled residents for a dental procedure of the 57 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #155 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a nurses note dated 4/8/14, documented the resident was .crying, indicating a tooth was hurting. Dental assistant was notified. Dentist examined tooth . Review of a nurses note from 4/8/14, forward, revealed no documentation the nursing staff made a follow up appointment for the tooth extraction until requested by the conservator. Review of a nurses note dated 4/28/14 documented, the .Conservator requested dental eval (evaluation) due to resident c/o (complaining of) tooth pain . The resident was receiving scheduled pain medication of [MEDICATION NAME] 7.5/325 mg three times daily. Review of a nurses note dated 4/29/14 at 11:00 AM, written by Nurse #11, documented .Called (dentist's office) to have dentist to look at resident's mouth to evaluated (evaluate) . Review of a nurses note dated 4/30/14 at 2:00 PM, written by Nurse #11 documented, .Dentist arrived talked to assistance (assistant) . Review of a nurses note dated on 4/30/14 at 2:00 PM, written by Nurse #4 documented, .Dentist at bedside with resident draped . Review of the dental progress note dated 4/30/14 documented, .Patient complaining lower right. Patient tolerated tx (treatment) well. Minimum bleeding. Already clotting . There was one tooth surgically removed requiring elevation, and two residual teeth roots were extracted. Interview with Nurse #11 on 1/15/15 at 7:30 AM, in the chart room, Nurse #11 stated, called the dentist's office to be sure the dentist would be coming to the facility on [DATE]. Interview with the Director of Nursing (DON), on 1/20/15 at 2:00 PM,… | 2018-05-01 |
| 6661 | 6661 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2015-02-11 | 441 | D | 0 | 1 | XIH911 | Based on policy review, observation and interview, the facility failed to ensure practices to prevent the spread of infection were maintained when 2 of 5 nurses (Nurses #19 and 21) administered medications without using proper hand hygiene and failed to sanitize reusable equipment between residents and 1 of 9 Certified Nursing Assistants (CNA #16) touched food and dining utensils without proper hand hygiene during meal service. The findings included: 1. Review of the facility's Infection Control / Cleaning and Disinfection of Resident-Care Items and Equipment policy documented, .c. Non-critical items are those that come in contact with intact skin but not mucous membranes . d. Reusable items are cleaned and disinfected or sterilized between residents ( .stethoscopes, durable medical equipment) . (2) . Stethoscopes are cleaned with an alcohol swab between each residents . Observations in Resident #67's room on 2/3/15 at 9:28 AM, revealed Nurse #19 took a stethoscope from the medication cart and placed it around her neck without cleaning it. Nurse #19 then entered the resident's room and checked Resident #67's blood pressure using the stethoscope. After administering medications to Resident #67, Nurse #19 placed the stethoscope in the medication cart without being cleaned. Interview with Nurse #19 on 2/5/15 at 3:17 PM, at the nurses' station, Nurse #19 was asked if she cleaned the stethoscope after using it for Resident #67. Nurse #19 stated, No, I didn't. Interview with the Director of Nursing (DON) on 2/10/15 at 4:58 PM in the DON's office, the DON was asked if she expected a nurse to clean a stethoscope after each resident. The DON stated, .clean before and after touching a resident . 2. Review of the facility's handwashing technique policy documented, .Turned faucet off with paper towel . Observations on the 100 hall on 2/3/15 at 8:44 AM, revealed Nurse #21 prepared medications for Resident #117. Nurse #21 entered Resident #117's room, washed her hands and turned the faucet off with her bare hands. Nurse #21 ha… | 2018-05-01 |
| 6662 | 6662 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2015-02-11 | 514 | E | 0 | 1 | XIH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of pharmacy consultant review, medical record review and interview, it was determined the facility failed to ensure medical records contained complete and accurate documentation of resident conditions related to post fall assessments and documentation, behavior monitoring, weekly nursing summaries, fall risk assessments, documentation of fall interventions, transcription of physician's orders [REDACTED].#6, 9, 25, 113, 118, 136, 150, 151, 152 and 153) sampled residents included in the stage 2 review. The findings included: 1. Review of the facility's policy Daily Charting, dated April 1994, documented .chart measures that will prevent and minimize further deterioration of the resident or can cause harm .follow up measures . the nursing interventions used . safety measures used to protect the resident from further or possible harm . Review of the facility's fall protocol, dated 4/22/10, documented .Whenever a resident has fallen, take the following actions to attempt to prevent further falls . Document the progress daily in the Licensed Progress Notes - x (times) 72 and weekly thereafter . Review of the facility's Protocol for Neurological (Neuro) Checks documented .neurological checks (level of consciousness, speech, motor ability, vital signs, pupil size and reaction to light) . performed on all residents with a suspected or known head injury . 2. Medical record review of Resident #6 documented admission on 4/26/10 with [DIAGNOSES REDACTED]. Review of the facility documentation dated 5/29/14 at 6:25 PM, revealed the resident was found on the floor in the hallway near the nurse's station. Interventions included every two hours (Q2H) fall monitoring and neurochecks. The facility documentation revealed neurochecks were initiated but not completed and Q2H fall monitoring was not initiated. Review of the facility documentation dated 1/29/15 at 5:00 PM, revealed the resident was found sitting on the floor beside . be… | 2018-05-01 |
| 8036 | 8036 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2013-11-20 | 164 | D | 0 | 1 | PDYI11 | Based on policy review, observation and interview, it was determined the facility failed to maintain the confidentiality of residents' medical records for 1 of 3 (Union Station) nursing units. The findings included: Review of the facility's Safeguarding Posted PHI (Protected Health Information) policy documented, .Policy . Protected health information (PHI) is not posted or displayed in a public location . Procedure . PHI intended for viewing by staff in resident care is not displayed by any means that might be viewed by visitors or staff who would normally not have access to the protected information . Observations at the union station nurses' station on 11/18/13 at 11:45 AM, revealed a clipboard with a MISSING BOWEL MOVEMENT REPORT on top of a medication cart. Residents' names were listed in full view to anyone who might pass by. During an interview in the Director of Nursing's (DON) office on 11/20/13 at 4:20 PM, the DON confirmed medical records/reports should be kept confidential. The DON stated, (Medical records/reports) should be covered up where can not see the records . | 2017-09-01 |
| 8037 | 8037 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2013-11-20 | 279 | D | 0 | 1 | PDYI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to have a care plan for a stage 2 pressure ulcer present on admission for 1 of 18 (Resident # 147) sampled residents reviewed of the 32 residents included in the stage 2 review. The findings included: Review of the facility's Resident Care Plan policy documented, .An interim care plan is to be completed upon admission . The Formula for a Care Plan . Identification of Problems, Needs . Care plan identifies the patient/resident problem, where you are with a resident . Medical record review for Resident #147 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] documented the resident had a stage 2 pressure ulcer on admission. Review of the facility's INITIAL DATA COLLECTION TOOL/NURSING SERVICE form dated 10/19/13 documented, .GENERAL SKIN CONDITION . open area . If stageable, identify level . Stage II (marked) . Review of the facility's PRESSURE ULCER STATUS RECORD dated 10/19/13 documented, .Date First Observed: 10/19/13 Location: coccyx Stage II . Review of the interim care plan dated 10/20/13 documented, .RESIDENT NEED . At Risk for Break in Skin Integrity . GOAL/TARGET DATE Maintain intact skin with no skin breaks by within 21 days . During an interview in Resident #147's room on 11/19/13 at 2:30 PM, Resident #147 stated, .I have a bedsore on my bottom and it was quite sore when I was admitted . During an interview in the Assistant Director of Nursing's (ADON) office on 11/19/13 at 4:00 PM, the ADON was asked if a resident is admitted with an actual pressure ulcer should it be on the care plan. The ADON stated, .it (the pressure ulcer) should be on here (indicating the 20th) . the Braden was done on the 20th . the wound nurse puts the wounds on the interim care plan if they are present on admission . The interim care plan dated 10/20/13 did not address the s… | 2017-09-01 |
| 8038 | 8038 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2013-11-20 | 280 | D | 0 | 1 | PDYI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to revise the comprehensive care plan for emergency bleeding related to [MEDICAL TREATMENT] for 1 of 18 (Resident #330) sampled residents of the 32 residents included in the stage 2 sample. The findings included: Review of the Clinical Services Polices & (and) Procedures, Nursing Volume I documented, .[MEDICAL TREATMENT] . For Emergency: a) Bleeding and hemorrhage - apply pressure to site and call 911 . Medical record review for Resident #330 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].Pt (patient) will need transport to [MEDICAL TREATMENT] Tues. (Tuesday), Thurs. (Thursday) + (and) Sat (Saturday). She will dialyze at (named [MEDICAL TREATMENT] center) . Review of the Minimum Data Set ((MDS) dated [DATE] documented, .End Stage [MEDICAL CONDITION] . Observations in Resident # 330's room on 11/19/13 at 5:05 PM, revealed Resident #330 was ambulating in the room with a bandage on the upper left arm. During an interview in the MDS Coordinators' office on 11/19/13 at 4:25 PM, MDS nurse #1 was asked if the care plan should address emergency bleeding. MDS nurse #1 stated, Yes. During an interview in Resident #330's room on 11/19/13 at 5:05 PM, Resident #330 stated, .I have just gotten back from [MEDICAL TREATMENT] and I am tired . | 2017-09-01 |
| 8039 | 8039 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2013-11-20 | 282 | D | 0 | 1 | PDYI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, it was determined the facility failed to ensure care plan interventions were followed for pain management for 1 of 18 (Resident #324) sampled residents reviewed of the 32 residents included in the stage 2 review. The findings included: Review of the facility's Pain Management - General Guidelines policy documented, .Policy . The goal of a pain management program is to control comfort level .The use of continuous narcotic administration has been well-documented to achieve more effective pain management goals than traditional prn (as needed) dosing .physician's orders [REDACTED].and frequency and route of administration . Medical record review for Resident #324 documented an admission date of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 9/12/13 documented, Problems . has alteration in comfort related to decreased mobility, arthritis, and metastatic [MEDICAL CONDITION] . Approaches . Administer scheduled pain medication . Review of the physician's orders [REDACTED].[MEDICATION NAME]/ACETAMIN ([MEDICATION NAME]) 5 MG (milligrams) -325 MG TABLET . [MEDICATION NAME] 1 TAB (tablet) BY MOUTH Q (every) 6 hours . (with a start date of 8/27/13) . Review of the September 2013 Medication Administration Records (MARS) documented Resident #324 did not receive her scheduled dose of [MEDICATION NAME]/[MEDICATION NAME] on 9/1/13 at 8:00 AM, 2:00 PM and 2:00 AM and on 9/2/13 at 2:00 AM. These entries were initialed by a nurse and circled, indicating the doses were not given. Review of the September, 2013 MARS documented, .MEDICATIONS NOT ADMINISTERED . 9/1/13 8 A (AM) . Medication . [MEDICATION NAME] . Reason . No distress Noted (Denies pain at this time) . 9/1/13 2 p (PM) . Medication . [MEDICATION NAME] . Reason . No distress noted . Review of the nurses' notes from 8/27/13 through 9/18/13 documented the resident denied pain or discomfort. During an interview … | 2017-09-01 |
| 8040 | 8040 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2013-11-20 | 309 | D | 0 | 1 | PDYI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of the [MEDICAL TREATMENT] agreement, observation and interview, it was determined the facility failed to follow physician's orders for pain management for 1 of 3 (Resident #324) sampled residents of the 3 residents receiving scheduled pain medications and failed to provide coordinated care for [MEDICAL TREATMENT] for 1 of 1 (Resident #330) sampled resident on [MEDICAL TREATMENT]. The findings included: 1. Review of the facility's Pain Management - General Guidelines policy documented, .Policy . The goal of a pain management program is to control comfort level . The use of continuous narcotic administration has been well-documented to achieve more effective pain management goals than traditional prn (as needed) dosing . Physician's orders will be obtained to include medication, concentration, dose/hour . and frequency and route of administration . Medical record review for Resident #324 documented an admission date of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 9/12/13 documented, Problems . has alteration in comfort related to decreased mobility, arthritis, and metastatic [MEDICAL CONDITION] . Approaches . Administer scheduled pain medication . Review of the physician's orders dated 9/14/13 documented, .[MEDICATION NAME]/ACETAMIN ([MEDICATION NAME]) 5 MG (milligrams) -325 MG TABLET . [MEDICATION NAME] 1 TAB (tablet) BY MOUTH Q (every) 6 hours . (with a start date of 8/27/13) . Review of the September 2013 Medication Administration Records (MARS) documented Resident #324 did not receive her scheduled dose of [MEDICATION NAME]/[MEDICATION NAME] on 9/1/13 at 8:00 AM, 2:00 PM and 2:00 AM and on 9/2/13 at 2:00 AM. These entries were initialed by a nurse and circled, indicating the doses were not given. Review of the September, 2013 MARS documented, .MEDICATIONS NOT ADMINISTERED . 9/1/13 8 A (AM) . Medication . [MEDICATION NAME] . Reason . No distress Noted (Denies p… | 2017-09-01 |
| 8041 | 8041 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2013-11-20 | 329 | D | 0 | 1 | PDYI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure each resident was free of unnecessary use of an antipsychotic medication for 1 of 5 (Resident #45) sampled residents of the 5 residents included in the stage 2 review for unnecessary medication usage. The findings included: Medical record review for Resident #45 documented an admission date of [DATE] with a re-admitted [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] and 11/14/13 documented, .Section E . Potential Indicators of [MEDICAL CONDITION] . none of the above . Section I . Active [DIAGNOSES REDACTED]. Section N . Medications . 7 of 7 days Antipsychotic . Review of Wellness Solutions Comprehensive Progress Note-Psychiatric dated 11/5/13 documented, .S . No s/s (signs and symptoms) of [MEDICAL CONDITION] . no behaviors reported by staff . 0 . Psychiatric MMSE (Mini Mental Status Exam) . [MEDICAL CONDITION] . no evidence . A . Impression . increased anxiety and depression d/t (due to) [MEDICAL CONDITION] and confusion . P . recommendations: no med changes at this time . Review of current Medication Administration Record [REDACTED]. Review of the current Behavior/Intervention Monthly Flow Record dated November, 2013 documented, zero (0) episodes of anxiety on 3 shifts from 11/1/13 through 11/19/13 and zero (0) episodes of Agitation on 3 shifts from 11/1/13 through 11/19/13. During an interview in the Director of Nursing's (DON) office on 11/20/13 at 11:40 AM, the DON was asked what [MEDICATION NAME] would be used for. The DON stated, a type of [MEDICAL CONDITION]. The DON was asked if you would expect a resident with a [DIAGNOSES REDACTED]. The DON stated, No, I would not. During an interview in the 200 hall nurses desk chart room on 11/20/13 at 11:48 AM, the DON was asked to find documentation in Resident # 45's chart to support the use of [MEDICATION NAME]. The DON s… | 2017-09-01 |
| 8042 | 8042 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2013-11-20 | 371 | E | 0 | 1 | PDYI11 | Based on policy review, observation and interview, it was determined the facility failed to ensure food was stored, prepared and distributed under sanitary conditions as evidenced by the staff working in the kitchen without hair covers or facial hair covers during 3 of 3 (11/18/13, 11/19/13 and 11/20/13) days of the survey. The findings included: 1. Review of the facility's Policy and Procedure for Nutrition Safety and Infection Control documented, .Chapter 1: Food and Nutrition Safety and Infection Control . Hair restraints must be worn at all times by food services associate and all hair must be restrained, particularly the bangs. A cap that is not clean or that does not cover all hair is not considered to be appropriate restraint . 2. During the initial tour of the kitchen on 11/18/13 at 10:00 AM, revealed the executive chef in the kitchen wearing a cap which did not cover the back of hair and the cook was not wearing a hair cover or a facial hair cover. 3. Observations on 11/19/13 at 11:45 AM, revealed the executive chef was not wearing a hair cover. 4. Observations on 11/20/13 at 9:30 AM, revealed the executive chef was not wearing a hair cover. 5. Observations at the tray line on 11/20/13 at 11:30 AM, the executive chef was not wearing a hair cover. 6. During an interview in the kitchen on 11/20/13 at 12:00 PM, the Registered Dietician (RD) was asked what the policy and procedure was for covering all hairs. The RD stated, Should wear all hair coverings at all times in the kitchen. | 2017-09-01 |
| 8043 | 8043 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2013-11-20 | 431 | D | 0 | 1 | PDYI11 | Based on policy review, observation and interview, it was determined the facility failed to ensure 2 of 4 (Nurses #3 and 4) medication nurses did not leave medications unattended and out of their sight. The findings included: 1. Review of the facility's Medication Storage & (and) Security in the Facility policy documented, .Policy . The medication supply is accessible only to licensed nursing personnel, or staff members lawfully authorized to have access . Procedure . Only licensed nurses, the consultant pharmacist, and those lawfully authorized are allowed access to medications . 2. Observations at the union station nurses' station on 11/18/13 at 11:45 AM, revealed a container labeled, GLUCAGON EMERGENCY KIT 10G (Gram) KIT . INJECT 1ML (Milliliters) IM (Intramuscularly) FOR ACCU CHECK LESS THAN . AND PT (Patient) UNABLE TO SWALLOW . on the medication cart unattended, nurses were at the nurses' station with back to cart. During an interview on 11/18/13 at 11:50 AM, Nurse #3 confirmed an injection was present in the container. Assistant Director of Nursing (ADON) #1 removed the container from the top of the medication cart. 3. Observations in Resident #300's room on 11/20/13 at 8:29 AM, revealed Nurse #4 left a Combivent inhaler and an Advair inhaler on the overbed table, left the room, and went to the medication cart in the hall to obtain water for the resident. The inhalers were unattended and out of her sight while she went to the medication cart to obtain the water. During an interview in the Director of Nursing's (DON) office on 11/20/13 at 4:20 PM, the DON was asked if medications should be left unattended. The DON stated, (Medications) should not be (left) unattended . | 2017-09-01 |
| 8044 | 8044 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2013-11-20 | 441 | D | 0 | 1 | PDYI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, it was determined the facility failed to ensure practices to prevent the potential spread of infection were maintained by 1 of 3 (Nurse #1) nurses observed performing an accucheck and Nurse #2 touched a resident's medication with her bare hands. The findings included: 1. Review of the facility's Cleaning and Disinfection of the Glucometer policy documented, .Equipment & (and) Supplies . Super Sani-Cloth or Sani-Cloth Plus wipe (individual wipe) or an equivalent product that kills hepatitis B and blood-borne pathogens . Policy . disinfect it (glucometer) with a Super Sani-Cloth wipe or an equivalent product that kills hepatitis B and blood-borne pathogens . Observations in room [ROOM NUMBER] on 11/20/13 at 11:50 AM, revealed Nurse #1 obtained a blood sample for an accucheck, exited the room, and cleansed the glucometer with an alcohol prep, and did not use a Super Sani-Cloth wipe to cleanse the glucometer. During an interview in the lobby on 11/20/13 at 12:10 PM, the Infection Control (IC) Nurse was asked what is used to clean the glucometer. The IC nurse stated, The Sani wipe with bleach. During an interview in the Director of Nursing's (DON) office on 11/20/13 at 4:25 PM, the DON confirmed the glucometer should not be cleaned with alcohol preps. The DON stated, We have Super Sani cloths they should use. 2. Review of the facility's Policies for Medication Administration policy documented, .Standard . All medications are administered safely and appropriately . Observations in Resident #379's room (during a resident interview) on 11/19/13 at 9:00 AM, Nurse #1 emptied pills from the packages and placed in a medication cup. Nurse #1 asked Resident #379, Do you want the large pill broken up? Resident #379 stated, Yes. Nurse #1 took the large pill out of the medication cup with her bare hands and broke the pill into with her thumbs. During an interview in the conference room on 11/20/13 at 11:45 AM… | 2017-09-01 |
| 8045 | 8045 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2013-11-20 | 514 | D | 0 | 1 | PDYI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to have accurate medical records for 1 of 32 (Resident #385) residents included in the stage 2 review. The findings included: Medical record review for Resident #385 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the INCIDENT FOLLOW-UP & (and) RECOMMENDATION FORM documented, .INCIDENT DATE 11-13-13 . attempted to ambulate from bed to bathroom s (without) assistance, pt (patient) stooped down, then sat in floor p (after) becoming weak . No injury noted . Review of the interim care plan dated 11/12/13 documented, .11/13/13 . Actual fall . Review of the FALL RISK EVALUATION form documented, .EVALUATION DATES . 11/12 . During the last 90 days the resident has had . 0 (indicating no falls) . 11/13 . 0 (indicating no falls) . During an interview in the conference room on 11/20/13 at 10:25 AM, the Director of Nursing (DON) was asked about the fall assessment done on 11/13/13. The DON stated fall assessments are done on admission and when a resident falls. The DON confirmed the assessment was inaccurate for 11/13/13. The DON stated, .should have been a 2 there (indicating falls) . | 2017-09-01 |
| 9136 | 9136 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2014-02-19 | 309 | D | 1 | 0 | YNEM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 080 Based on medical record review, observation and interview, it was determined the facility failed to follow the physician's order for 1 of 5 sampled residents reviewed. The findings included: Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. with Hallucinations, Partial Bowel Obstruction and Gastro [MEDICAL CONDITION] Reflux Disease. Review of the Physician's Orders dated 2/6/14 documented, .APPLY PSA (pressure sensitive alarm) TO BED & (and) W/C (wheelchair) Q (every) SHIFT . Observations on the 300 hall on 2/19/14 at 10:00 AM, revealed Resident #5 in a w/c, being pushed down the hall wearing a Velcro self release belt on, with no pressure sensitive alarm in place as ordered. Observation in Resident #5's room on 2/19/14 at 3:05 PM, revealed Resident #5 lying in bed, with his w/c at the foot of the bed with a Velcro self release belt laying in the w/c, with no pressure sensitive alarm in place as ordered. Observations on the 300 hall on 2/19/14 at 4:00 PM, revealed Resident #5 sitting in a w/c, wearing a Velcro self release belt, with no pressure sensitive alarm in place as ordered. During an interview in the conference room on 2/19/14 at 5:40 PM, the Director of Nursing stated, .When he came back on the admission order the PSA was ordered (Pressure Sensitive Alarm) . He is supposed to have the PSA and not the self release . | 2017-02-01 |
| 9716 | 9716 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2013-11-21 | 282 | D | 1 | 0 | K9D611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 652 Based on policy review, observation and interview, it was determined the facility failed to ensure care plan interventions were followed for pain management for 1 of 16 (Resident #324) sampled residents reviewed for the complaint investigation. The findings included: Review of the facility's Pain Management - General Guidelines policy documented, .Policy . The goal of a pain management program is to control comfort level .The use of continuous narcotic administration has been well-documented to achieve more effective pain management goals than traditional prn (as needed) dosing .physician's orders [REDACTED].and frequency and route of administration . Medical record review for Resident #324 documented an admission date of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 9/12/13 documented, Problems . has alteration in comfort related to decreased mobility, arthritis, and metastatic [MEDICAL CONDITION] . Approaches . Administer scheduled pain medication . Review of the physician's orders [REDACTED].[MEDICATION NAME]/ACETAMIN ([MEDICATION NAME]) 5 MG (milligrams) -325 MG TABLET . [MEDICATION NAME] 1 TAB (tablet) BY MOUTH Q (every) 6 hours . (with a start date of 8/27/13) . Review of the September 2013 Medication Administration Records (MARS) documented Resident #324 did not receive her scheduled dose of [MEDICATION NAME]/[MEDICATION NAME] on 9/1/13 at 8:00 AM, 2:00 PM and 2:00 AM and on 9/2/13 at 2:00 AM. These entries were initialed by a nurse and circled, indicating the doses were not given. Review of the September, 2013 MARS documented, .MEDICATIONS NOT ADMINISTERED . 9/1/13 8 A (AM) . Medication . [MEDICATION NAME] . Reason . No distress Noted (Denies pain at this time) . 9/1/13 2 p (PM) . Medication . [MEDICATION NAME] . Reason . No distress noted . Review of the nurses' notes from 8/27/13 through 9/18/13 documented the resident denied pain or discomfort. During an interview in … | 2016-11-01 |
| 9717 | 9717 | LIFE CARE CENTER OF HICKORY WOODS | 445507 | 4200 MURFREESBORO PIKE | ANTIOCH | TN | 37013 | 2013-11-21 | 309 | D | 1 | 0 | K9D611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 652 Based on policy review, medical record review and interview, it was determined the facility failed to follow physician's orders for scheduled pain medication for 1 of 3 (Resident #324) sampled residents reviewed receiving schedule pain medication. The findings included: Review of the facility's Pain Management - General Guidelines policy documented, .Policy . The goal of a pain management program is to control comfort level . The use of continuous narcotic administration has been well-documented to achieve more effective pain management goals than traditional prn (as needed) dosing . Physician's orders will be obtained to include medication, concentration, dose/hour . and frequency and route of administration . Medical record review for Resident #324 documented an admission date of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 9/12/13 documented, Problems . has alteration in comfort related to decreased mobility, arthritis, and metastatic [MEDICAL CONDITION] . Approaches . Administer scheduled pain medication . Review of the physician's orders dated 9/14/13 documented, .[MEDICATION NAME]/ACETAMIN ([MEDICATION NAME]) 5 MG (milligrams) -325 MG TABLET . [MEDICATION NAME] 1 TAB (tablet) BY MOUTH Q (every) 6 hours . (with a start date of 8/27/13) . Review of the September 2013 Medication Administration Records (MARS) documented Resident #324 did not receive her scheduled dose of [MEDICATION NAME]/[MEDICATION NAME] on 9/1/13 at 8:00 AM, 2:00 PM and 2:00 AM and on 9/2/13 at 2:00 AM. These entries were initialed by a nurse and circled, indicating the doses were not given. Review of the September, 2013 MARS documented, .MEDICATIONS NOT ADMINISTERED . 9/1/13 8 A (AM) . Medication . [MEDICATION NAME] . Reason . No distress Noted (Denies pain at this time) . 9/1/13 2 p (PM) . Medication . [MEDICATION NAME] . Reason . No distress noted . Review of the nurses' notes from 8/27/13 through 9/18/… | 2016-11-01 |
| 10645 | 10645 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2011-11-16 | 241 | E | 0 | 1 | 0RV411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, it was determined the facility failed to ensure that staff knocked on the door or gained permission prior to entering the resident's room during 2 of 2 dining observations (the evening meal on 11/14/11 and lunch on 11/15/11) and 1 of 1 nurses (Nurse #10) during 1 of 1 dressing changes. The findings included: 1. Review of the facility's Resident Rights Guidelines for All Nursing Procedures policy documented, .a. Knock and gain permission before entering the resident's room . a. Observations on the 100 wing on 11/14/11 at 5:10 PM revealed Certified Nursing Assistant (CNA) #2 entered room [ROOM NUMBER] with a meal without knocking or gaining permission to enter. b. Observations on the 600 wing on 11/14/11 at 5:48 PM revealed CNA #4 entered room [ROOM NUMBER] to get gloves without knocking or gaining permission to enter. c. Observations on the 600 wing on 11/14/11 at 5:50 PM revealed CNA #4 entered room [ROOM NUMBER], removed her gloves and placed the gloves in the trash, then donned clean gloves without knocking or gaining permission to enter. d. Observations on the 500 wing on 11/14/11 at 5:55 PM revealed CNA #5 entered room [ROOM NUMBER] to obtain gloves without knocking or gaining permission to enter. e. Observations on the 200 wing on 11/15/11 at 12:20 PM revealed CNA #6 entered room [ROOM NUMBER] with a meal tray without knocking or gaining permission to enter. f. During an interview on the 300 wing on 11/16/11 at 1:50 PM, when asked about expectations of staff before entering residents rooms, the Director of Nursing stated, .Knock, state who you are . 2. Observations in room [ROOM NUMBER] on 11/15/11 at 8:40 AM revealed Nurse #10 entered room [ROOM NUMBER] twice without knocking on the door or gaining permission for entrance to perform dressing change. During an interview in the marketing office with the Administrator on 11/15/11 at 10:00 AM, when asked his expectations of staff entering r… | 2016-05-01 |
| 10646 | 10646 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2011-11-16 | 278 | E | 0 | 1 | 0RV411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to ensure the Minimum Data Set (MDS) was accurate for functional limitation, corrective lenses, pain and restraints for 4 of 15 (Residents #2, 4, 6 and 10) sampled residents. The findings included: 1. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE] assessed Resident #2 for Functional Limitation in Range of Motion with Upper and Lower Extremity impairment on one side related to the [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] assessed Resident #2 with no Functional Limitation in Range of Motion and no impairment with Upper and Lower Extremities. Observation at the nurses's station on 11/14/11 at 11:20 AM revealed Resident #2 seated in a wheelchair with a lap buddy in place. His right arm was bent at the elbow and held next to his body. His right hand was closed in a fist. Observations on 11/14/2011 at 3:05 PM and 5:40 PM, and 11/15/11 at 7:36 AM, 9:20 AM, and 12:30 PM revealed the resident's right arm and hand contracted in the same position. During an interview in the MDS office on 11/15/11 at 9:25 AM, Nurse #2 was asked if Resident #2 was admitted with right-sided weakness and if he had any improvement of the impairment at any time since admission. Nurse #2 stated Resident #2 was admitted to the facility with right-sided impairment from [MEDICAL CONDITION] had no improvement. Resident #2's annual and quarterly MDS assessments were reviewed with Nurse #2. The nurse verified that the quarterly assessment dated [DATE] and every assessment completed since 10/10 were inaccurate related to Resident #2's Functional Limitation in Range of Motion. 2. Medical record review for Resident #4 documented an admission date of [DATE] and a readmission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] documented, .Secti… | 2016-05-01 |
| 10647 | 10647 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2011-11-16 | 280 | D | 0 | 1 | 0RV411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to revise the current care plan for a shoulder sling and a hearing aid for 1 of 15 (Resident #4) sampled residents. The findings included: 1. Review of the facility's Care Plans policy documented, .4. Care plans are revised as changes in the resident's condition dictate . Medical record review for Resident #4 documented an admission date of [DATE] and a readmission date of [DATE] with a [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].Rt (right) UE (upper extremity) immobilized to wear sling @ (at) all times 2 (secondary) (symbol for degree) to Rt anterior shoulder dislocation . Review of a physician's orders [REDACTED].Patient to wear R (right) UE shoulder sling whenever out of bed or in wheelchair .Patient to wear R UE wrist/hand pan splint whenever out of bed or in wheelchair . Review of the care plan dated 12/15/10 and updated 9/2/11 documented, .Decreased Hearing Impaired .(symbol for check mark) Assist with hearing aid placement and maintenance . Review of the care plan dated 12/15/10 and updated 9/2/11 documented no intervention for the immobilizer or the shoulder sling and splint. Observations in Resident #4's room on 11/14/11 at 11:17 AM, 3:15 PM and 4:30 PM revealed Resident #4 with his Rt UE in a sling with an immobilizer and hand splint. Observations in the Dining Room on 11/15/11 at 7:25 AM and 12:00 PM revealed Resident #4 with his Rt UE in a sling with an immobilizer and hand splint. Observations on the 300 wing on 11/15/11 at 9:30 AM revealed Resident #4 with his Rt UE in a sling with an immobilizer and hand splint. No hearing aid was noted during any of the observations on 11/14/11 and 11/15/11. During an interview at the nurses' station on 11/16/11 at 8:35 AM, when asked if the sling immobilizer was on the care plan, Nurse #8 stated, .I don't see it . and confirmed that it should be on the care plan.… | 2016-05-01 |
| 10648 | 10648 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2011-11-16 | 281 | D | 0 | 1 | 0RV411 | Based on review of Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach, Third Edition, policy review, observation and interview, it was determined the facility failed to ensure that 2 of 6 (Nurse #3 and 5) nurses observed during medication pass followed accepted standards of clinical practice. The findings included: 1. Review of Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach, Third Edition:, page 1273 documented, .Administering Oral Medications .Documentation: Immediately on leaving client, note medication given and omitted on medication sheet and/or in computer . Page 1275 documented, .Administering Topical Medications .Before applying a topical medication, cleanse the skin thoroughly but gently with warm water and nondrying soap . 2. Review of the facility's Medication Administration policy documented, .The individual administering the medication must initial the resident's MAR (medication administration record) on the appropriate line after giving the medications . 3. Observations at the 100 Wing medication cart on 11/15/11 at 4:40 PM and at 5:00 PM revealed Nurse #3 initialed the MAR, verifying that medication had been given, before administering the medications. During an interview in the Director of Nursing (DON) office on 11/16/11 at 11:00 AM, the DON was asked when nurses should initial that medications were administered. The DON stated, .After consumption . 4. Observations in Resident #6's room on 11/15/11 at 7:30 AM revealed Nurse #5 applied 2 topical medication patches without cleansing the skin prior to application. During an interview in the 600 Wing on 11/16/11 at 10:30 AM, when asked about cleansing the skin prior to applying topical medications, Nurse #5 stated, .Yes, the site should have been cleaned prior to applying a new patch . | 2016-05-01 |
| 10649 | 10649 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2011-11-16 | 323 | D | 0 | 1 | 0RV411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to follow physician's orders and to ensure the care plan was followed for 2 of 15 (Resident #4 and 9) sampled residents assessed for fall risk. The findings included: 1. Medical record review for Resident #4 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders dated 10/31/11 documented, .APPLY PSA (pressure sensor alarm) WHILE IN BED Q (every) SHIFT . Review of the care plan dated 12/10/11 and updated 9/2/11 documented, .PSA to bed . Observations in Resident #4's room on 11/14/11 at 3:15 PM and 4:30 PM, revealed Resident #4 in bed with no PSA on the bed. During an interview in Resident #4's room on 11/16/11 at 10:30 AM, when asked if Resident #4 had a PSA on the bed, Nurse #7 confirmed Resident #4 did not have a PSA on the bed. 2. Medical record review for Resident #9 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders dated 10/31/11 documented, .APPLY BODY ALARM WHEN UP IN WHEELCHAIR & WHEN IN BED QSHIFT . Review of the care plan dated 10/7/11 documented, .Clip alarm to bed & w/c (wheelchair) . Observations in Resident #9's room on 11/15/11 at 10:00 AM, 12:00 AM and 3:15 AM revealed Resident #9 in bed with no body alarm in place. During an interview in Resident #9's room on 11/15/11 at 3:25 PM Nurse #9 confirmed Resident #9 did not have a body alarm in place. | 2016-05-01 |
| 10650 | 10650 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2011-11-16 | 332 | E | 0 | 1 | 0RV411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the GERIATRIC MEDICATION HANDBOOK, policy review, medical record review, observation and interview, it was determined the facility failed to ensure 3 of 6 (Nurse #5, 6 and 7) nurses administered medications with a medication error rate less than five percent (%). There were 5 medication errors made out of 42 opportunities for error which resulted in a medication error rate of 11.9%. The findings included: 1. Review of the GERIATRIC MEDICATION HANDBOOK Tenth Edition provided by the American Society of Consultant Pharmacists documented, .DIABETES: INJECTABLE MEDICATIONS .[MEDICATION NAME] R .Regular insulin .ONSET .0.5-1 (hour) .TYPICAL ADMINISTRATION/COMMENTS .30 minutes prior to meals .page 41 .Inhaled Medications .If another puff of the same or different medication is required, wait 1-2 minutes, then repeat procedures .For steroid inhalers, provide resident with cup of water and instruct him/her to rinse mouth and spit water back into cup .page 57 .EYEDROP ADMINISTRATION .If additional drops of the same or different medication are required in the same eye, wait 3-10 minutes .and repeat procedures .page 60 . 2. Review of the facility's Medication Administration policy documented, .Medications must be administered in accordance with the orders .The individual administering medications must verify the right medication, right dosage, right time and right method of administration before giving the medication . 3. Medical record review for Random Resident (RR) #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].Artificial tears 1 drop q (every) hour prn (as needed) x (times) 10 days (both eyes) .[MEDICATION NAME] 1 drop qid (4 times daily) both eyes x 10 days . Review of the physician's recertification orders dated 10/31/11 documented, .[MEDICATION NAME] SPRAY EACH NOSTRIL 2 SPRAYS QD/A (once a day) . Observations in RR #1's room on 11/15/11 at 8:35 AM revealed Nurse #6 … | 2016-05-01 |
| 10651 | 10651 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2011-11-16 | 333 | D | 0 | 1 | 0RV411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the GERIATRIC MEDICATION HANDBOOK, medical record review, observation and interview, it was determined the facility failed to ensure that residents were free of significant medication errors. During the medication pass observation 1 of 3 (Nurse #7) nurses failed to administer insulin within the proper time frame before meals. The findings included: Review of the GERIATRIC MEDICATION HANDBOOK Tenth Edition provided by the American Society of Consultant Pharmacists documented, .DIABETES: INJECTABLE MEDICATIONS .[MEDICATION NAME] R .Regular insulin .ONSET .0.5-1 (hour) .TYPICAL ADMINISTRATION/COMMENTS .30 minutes prior to meals .page 41 . Medical record review for RR #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's recertification orders dated 11/6/11 documented, .ACCUCHECK TID (three times a day) AC (before meals) WITH SLIDING SCALE OF REGULAR INSULIN AS FOLLOWS: .151 - 200 (blood sugar results) = 3 UNITS (insulin to be given) . Observations in RR #3's room on 11/15/11 at 11:22 AM revealed Nurse #7 administered 3 units of [MEDICATION NAME] R (regular insulin) to RR #6 for a blood sugar of 184. The resident did not receive his lunch tray until 12:20 PM. The administration of the [MEDICATION NAME] R 58 minutes before lunch was served and the resident took his first bite of food resulted in a significant medication error. During an interview on the 300 wing on 11/16/11 at 10:45 AM, when asked about insulin administration and meal service, Nurse #7 confirmed that the resident should have been served a meal within 30 minutes after [MEDICATION NAME] R was administered. During an interview in the Director of Nursing (DON) office on 11/16/11 at 11:00 AM, when asked about her expectations concerning regular insulin administration and meal service, the DON stated, .within 30 minutes . | 2016-05-01 |
| 10652 | 10652 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2011-11-16 | 431 | D | 0 | 1 | 0RV411 | Based on review of Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach, Third Edition, policy review, observation and interview, it was determined the facility failed to ensure that 1 of 6 (Nurse #5) nurses did not leave medications unattended and out of view. The findings included: Review of Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach, Third Edition page 1273 documented, .Medication left at the bedside without an order interferes with safe practice . Review of the facility's Medication Administration policy documented, .Medications should never be left unattended . Observations in RR #5's room on 11/15/111 at 9:37 AM revealed nurse #5 left a cup of medications and a metered dose inhaler on the residents beside table to wash his hands in the resident's bathroom. The medications were left unattended and out of view of the nurse. During an interview in the Director of Nursing (DON) office on 11/16/11 at 11:00, when asked about leaving medications unattended and out of view, the DON stated, .They know not to leave the meds (medications) with the patient . | 2016-05-01 |
| 10653 | 10653 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2011-11-16 | 441 | E | 0 | 1 | 0RV411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, it was determined the facility failed to ensure Certified Nursing Assistants (CNAs) and nurses followed infection control practices to prevent the spread of infection by not using sanitary hand hygiene during 2 of 2 dining observations (evening meal on 11/14/11 and lunch on 11/15/11), 1 of 1 dressing change observations and 1 of 6 (Nurse #6) nurses observed during medication pass. Two (2) of 3 (Nurse #3 and 4) failed to disinfect the glucometer. The findings included: 1. Review of the facility's Handwashing/Hand Hygiene policy documented, .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Handwashing and Hand Hygiene means using soap and water .m. After handling soiled or used linens, dressings .r. Before handling clean or soiled dressings .u. After removing gloves .6. Hand hygiene is always the final step after removing and disposing of personal protective equipment .7. The use of gloves does not replace handwashing/hand hygiene . a. Observations on the 300 wing on 11/14/11 at 5:25 PM revealed CNA #3 donned gloves, entered room [ROOM NUMBER], placed the tray on the table, removed his gloves, washed his hands, then turned the water off with his bare hand, dried his hands and applied gloves. CNA #3 set up the tray, took his gloves off, donned a clean pair of gloves, picked up a urinal, emptied the urinal and removed his gloves. CNA #3 donned clean gloves without washing his hands, then returned to the tray cart and rolled the cart to the 200 wing. b. Observations on the 200 wing on 11/14/11 at 5:33 PM revealed CNA #3 entered room [ROOM NUMBER], placed the tray on the table, removed his gloves, washed his hands, turned the water off with his bare hands, then dried his hands and applied clean gloves. c. Observations in room [ROOM NUMBER] on 11/14/11 at 5:35 PM revealed CNA #3 and CNA #4 assi… | 2016-05-01 |
| 10654 | 10654 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2011-11-16 | 504 | D | 0 | 1 | 0RV411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to obtain a physician's order for laboratory services for 1 of 15 (Resident #1) sampled residents. The findings included: Review of the facility's Lab and Diagnostic Test Results - Clinical Protocol policy documented, .The physician will identify and order diagnostic and lab testing . Medical record review for Resident #1 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders documented no order for a Stool Culture and [MEDICAL CONDITION] Culture on 10/18/11 and [MEDICAL CONDITION] and [MEDICAL CONDITION] Toxin on 10/25/11. There were test results that reflected a Stool Culture and [MEDICAL CONDITION] Culture were obtained on 10/18/11 and a [MEDICAL CONDITION] and [MEDICAL CONDITION] Toxin were obtained on 10/25/11. During an interview at the nurses' station on 11/15/11 at 9:15 AM, the Director of Nursing (DON) was asked if there was an order for [REDACTED]. | 2016-05-01 |
| 12923 | 12923 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2010-08-25 | 514 | D | 0 | 1 | 0TLC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and interviews, it was determined the facility failed to ensure bowel movements were accurately documented for 2 of 20 (Residents #1 and 6) sampled residents. The findings included: 1. Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's August 2010's "Nurse Aides Notes" revealed no bowel movements were documented from 8/4/10 through 8/15/10 for Resident #1. During an interview at the nurse's station on 8/24/10 at 2:40 PM, Certified Nursing Assistant (CNA) #4 stated, "She (Resident #1) does not go over 3 days without a BM (bowel movement) ...She (Resident #1) tells us when she wants to go. If she did not have a BM, I would tell the nurse." 2. Medical record review for Resident #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's August 2010's "Nurse Aides Notes" for the 2:30 AM to 11:00 PM revealed Resident #6 had no bowel movement documented from 8/20/10 through 8/24/10. Observations in Resident #6's room on 8/23/10 at 4:10 PM, revealed Resident #6 sitting on the mattress on the floor. Resident #6 pulled her pants and diaper off revealing a bowel movement in the diaper. Certified Nursing Technicians (CNT) #1 and 3 cleaned Resident #6 and changed her clothes. During an interview at the nurse's station on 8/24/10 at 12:15 PM, Nurse #3 was asked where a resident's bowel movement would be documented. Nurse #3 stated, "...The CNT writes it (bowel movement) down on the aide notes. After reviewing the August 2010 nurse aides notes. Nurse #3 stated, "The CNT didn't write it (bowel movement) down." During an interview at the nurse's station on 8/24/10 at 4:00 PM, CNT #1 reviewed the August 2010 nurse aide notes. CNT #1 stated, "I know she (Resident #6) had a BM yesterday. It (bowel movement) didn't get wrote in on the sheet." | 2015-06-01 |
| 12924 | 12924 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2010-08-25 | 258 | E | 0 | 1 | 0TLC11 | Based on review of resident council minutes, observation and the group interview, it was determined the facility failed to maintain comfortable sound levels for 5 of 7 alert and oriented residents Random Residents (RR) #3, 4, 5, 6 and 7) participating in the group interview. The findings included: 1. Review of the February 2010 resident council minutes documented, "Techs are being too loud in morning." Review of the March 2010 resident council minutes documented, "...Too loud in mornings: staff and carts. Has been reported but nothing done..." 2. Observations during the initial tour of the 300 hall on 8/23/10 at 10:25 AM, a Certified Nursing Technician (CNT) was yelling down the hallway to another CNT. 3. During the group interview in the fine dining room on 8/23/10 at 3:00 PM, five alert and oriented residents voice the following: a. RRs #3, 4, 5 and 6 complained of "...noisy when staff getting off in the morning and when passing out the meal trays..." b. RR #7 stated, "I would really like to see the noise issue really worked on." c. RR #3 stated the noise was worse "between 6:30 AM and 7:15 AM (staff are) laughing and talking." | 2015-06-01 |
| 12925 | 12925 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2010-08-25 | 441 | D | 0 | 1 | 0TLC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, it was determined 2 of 5 (Nurses #1 and 2) nurses failed to follow infection control practices by not washing their hands during a dressing change or during medication pass. The findings included: 1. Observations in Resident #8's room on 8/23/10 at 4:15 PM, revealed Nurse #2 donned gloves, performed a fingerstick to check Resident #8's blood sugar level, removed the gloves and cleaned her hands with hand sanitizer. Nurse #2 returned to the medication cart and drew up the [MEDICATION NAME] R insulin for an injection. Nurse #2 entered Resident #8's room and washed her hands. Nurse #2 turned the water off with her bare hand and then dried her hands. Nurse #2 donned gloves, administered the injection of insulin into the abdomen of Resident #8, removed her gloves, and returned to the medication cart. Nurse #2 did not wash her hands after removing her gloves. During an interview at the nurse's station on 8/25/10 at 11:05 AM, the Director of Nursing (DON) was asked when would she expect a nurse to wash her hands. The DON stated, "It is our practice to wash hands when going into a room, after providing care, after removing gloves and before leaving the room. 2. Observations during a dressing change in Random Resident (RR) #1's room on 8/23/10 at 4:55 PM, revealed Nurse #1 washed his hands, pulled the curtain, donned gloves, assisted in turning RR #1, removed his gloves, donned another pair of gloves and proceeded to clean the wound. Nurse #1 did not wash his hands between assisting RR #1 to turn and starting the dressing change. 3. Observations in RR #2's room on 8/24/10 at 2:30 PM, Nurse #1 performed a dressing change on RR #2. After Nurse #1 washed his hands in RR #2's restroom, he returned to the hallway and opened the treatment book and then the treatment cart. Nurse #1 then removed a biohazard bag and scissors and to cut the bag in half. Half of the bag was used for trash and the other half was used for a cl… | 2015-06-01 |
| 12926 | 12926 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2010-08-25 | 280 | D | 0 | 1 | 0TLC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and an interview, it was determined the facility failed to revise the care plan for emergency bleeding for 1 of 20 (Resident #13) sampled residents. The findings included: Medical record review for Resident #13 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the initial care plan dated 8/19/10 revealed no documentation of interventions for emergency bleeding. During an interview in the Director of Nursing's (DON) office on 8/25/10 at 10:00 AM, Nurse #5 was asked if Resident #13's plan of care addressed emergency bleeding. Nurse #5 stated, "Monitor the site for bleed but not the next steps. It's not on there. I failed to add that. I'll get it fixed." | 2015-06-01 |
| 14181 | 14181 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2010-02-17 | 226 | E | FOGM11 | Based on policy review, review of personnel files and interview, it was determined the facility failed to implement policies for the prevention of abuse, neglect, mistreatment and misappropriation of property by providing incomplete screening of 45 of 54 (Employees #1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 18, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 44, 46, 47, 49, 50, 52, 53 and 54) sampled employees. The findings included: Review of the facility's "Prevention of Resident Abuse" policy documented, "...Before hiring, all applicants are screened by reviewing their applications, calling past employers for references... verify certification, background checks... Screening Components... references ...certification/license verification... criminal background checks..." Review of facility personnel files of employees hired since 6/1/2009 revealed the following information was not completed: a. License or certification verification - Employee #1, 2, 12, 14, 42 and 52. b. Documentation of reference checks - Employee #1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 18, 19, 21, 22, 23, 24, 25, 26, 27, 29, 31, 33, 34, 35, 36, 44, 46, 47, 49, 50, 52, 53, and 54. c. Abuse registry checks - Employee #1, 2, 7, 12, 42, and 52. d. Criminal background checks - Employee #1, 2, 4, 5, 7, 9, 27, 28, 30, 31, 37, 38, 39, 40, 41, 42, 50, and 52. During an interview in the consultation room, on 2/17/10 at 8:30 AM, the Administrator confirmed the screening information was not documented as required. | 2014-03-01 | ||
| 14182 | 14182 | GOOD SAMARITAN HEALTH AND REHAB CENTER | 445170 | 500 HICKORY HOLLOW TERRACE | ANTIOCH | TN | 37013 | 2010-02-17 | 323 | E | FOGM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to identify risk, and develop and implement interventions to prevent recurrent falls for 2 of 4 (Residents #5 and 10) sampled residents with falls. The findings included: 1. Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]." Review of the quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #5's cognitive skills were assessed as "SEVERELY IMPAIRED" and "SOMETIMES UNDERSTANDS" simple direct communication. Resident #5 required "EXTENSIVE ASSISTANCE" with transfers, did not ambulate and was assessed as "TOTAL DEPENDENCE" with wheelchair locomotion. Resident #5 fell in the past 31 to (-) 180 days and required a trunk restraint. Review of the Care Plan updated 10/19/09 identified Resident #5 as a "FALL RISK... POTENTIAL FOR INJURY Related to ...Unsteady Gait...Cognitive Deficit... Weakness... Impaired Vision (Blind)... As evidenced by... History of falls... APPROACHES... Labs (laboratory tests)/diagnostic work as ordered... for abnormal results... Move to room closer to nurse's station... Shoes well-fitting with non-slip soles... PT/OT (physical therapy/occupational therapy) eval (evaluation) or Restorative nursing for strength training, gait, or transfer... Side rails up x (times) 2... Maintain room and hall ways free of clutter..." and requiring "RESTRAINT... Related to use of...Non-accessible seatbelt... APPROACHES...Make sure restraint is applied properly... Provide verbal reminders to resident to call when needing assistance... Keep call light and most frequently used personal items within reach..." Review of the nurses' notes dated 11/23/09 documented, "Resident (#5) was found on the floor on his side with the w/c (wheelchair) almost on his side with his NASB (non-accessible seat belt) attached... All staff inservice (inserviced) about fall and saf… | 2014-03-01 | ||
| 1883 | 1883 | HILLCREST HEALTHCARE CENTER | 445316 | 111 E PEMBERTON STREET | ASHLAND CITY | TN | 37015 | 2019-05-21 | 580 | D | 0 | 1 | UFDY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to notify the physician for 2 of 2 (Resident #22 and #53) sampled residents reviewed for pressure ulcers and bowel function. The findings include: 1. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admit/Readmit Screener dated 4/30/19 documented, .Right buttock .Pressure .Left buttock .Pressure . The physician's orders [REDACTED].Barrier cream to BIL (bilateral) buttocks r/t (related to) pressure injury every shift for pressure injury .Order Date .4/30/2019 . Observations in Resident #22's room on 5/19/19 at 10:39 AM, revealed a half dollar size open area to her right buttock. Thyere was no documentation in the medical record th physician had been notified of this wound. Telephone interview with the Wound Care Doctor on 5/21/19 at 3:28 PM, the Wound Care Doctor was asked if he expected the nursing staff to contact him about any identified pressure ulcers. The Wound Care Doctor stated, Absolutely. The Wound Care Doctor was asked if he had seen Resident #22's buttock wound. The Wound Care Doctor stated, .I did not know about it . 2. The facility's Bowel Policy . dated 12/30/11 documented, .if there is not a bowel movement past completion of bowel protocol, notify the physician . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 1/29/19 documented, .Problem .I have the potential for constipation r/t (related to) Decreased mobility, Pain med (medication) use .Interventions .will receive laxatives and stool softeners as needed/ordered .alert MD (Medical Doctor) if not effective . Review of the (MONTH) 2019 Treatment Administration Record revealed Resident #53 had not had a bowel movement from 2/13/19 through 2/22/19. Interview with the Nurse Practitioner (NP) on 5/21/19 at 12:30 PM, in the Staff Development Roo… | 2020-09-01 |
| 1884 | 1884 | HILLCREST HEALTHCARE CENTER | 445316 | 111 E PEMBERTON STREET | ASHLAND CITY | TN | 37015 | 2019-05-21 | 684 | D | 0 | 1 | UFDY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to administer treatment to restore normal bowel function for 1 of 1 (Resident #53) sampled residents reviewed for bowel function. The findings include: The facility's Bowel Policy . dated 12/30/11 documented, .beginning of the 3rd day of no B.M (bowel movement) Administer [MEDICATION NAME] 17 gram, mix with prune juice or beverage of choice, wait 4 hours, if no bowel movement repeat one time, wait 2 hours. Apply one ducalox ([MEDICATION NAME]) sup (suppository) rectally, wait 2 hours. Administer fleets enema one rectally, wait 2 hours . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 1/29/19 documented, .Problem .I have the potential for constipation r/t (related to) Decreased mobility, Pain med (medication) use .Interventions .receive laxatives and stool softeners as needed/ordered nurse will monitor the effectiveness of laxatives that I receive .staff will monitor my BM record daily, report to charge nurse and if no BM >(greater than) 3 days initiate BM protocol . The progress note dated 2/22/19 documented, .Resident has not had a bowel movement in 10 days . Review of the (MONTH) 2019 Treatment Administration Record revealed there was no documentation that the [MEDICATION NAME] or Fleets Enema had been given per the bowel protocol. Interview with the Director of Nursing (DON) on 5/21/19 at 12:21 PM, in the Staff Development Room, the DON confirmed there was no documentation that [MEDICATION NAME] and Fleets Enema had been given per the bowel movement protocol. | 2020-09-01 |
| 1885 | 1885 | HILLCREST HEALTHCARE CENTER | 445316 | 111 E PEMBERTON STREET | ASHLAND CITY | TN | 37015 | 2019-05-21 | 686 | D | 0 | 1 | UFDY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to identify and assess 1 of 3 (Resident #22) sampled residents reviewed for pressure ulcers. The findings include: The facility's Wound Care policy dated 12/1/05 documented, .Document site, size, description of site, condition of skin around site, treatment started and who the pressure ulcer was reported to . The Facility's Standing Orders policy dated 5/30/18 documented, .Barrier Cream or [MEDICATION NAME] for reddened or excoriated skin .follow skin protocol for stg (stage) 1-4 pressure ulcers . Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admit/Readmit Screener dated 4/30/19 documented, .Right buttock .Pressure .Left buttock .Pressure . The physician's orders [REDACTED].Barrier cream to BIL (bilateral) buttocks r/t (related to) pressure injury every shift for pressure injury .Order Date .4/30/2019 . There was no documentation for wound description, wound measurements, or wound staging. Observations in Resident #22's room on 5/19/19 at 10:39 AM, revealed a half dollar size open area to Resident #22's right buttock. The facility was unable to provide documentation that weekly assessments or measurements of Resident #22's wound had been done. Interview with the Unit Manager on 5/21/19 at 9:29 AM, in the in Staff Development Room, the Unit Manager was asked if the nursing staff should complete an assessment and measurement on wounds when they are identified. The Unit Manager stated, Yes. Interview with the Director of Nursing (DON) on 5/21/19 at 11:51 AM, at the Nurses' Station, the DON was asked what the nursing staff should do when they identified a wound. The DON stated, They should notify the Unit Manager .complete the assessment with the description .what they found .follow-up with the protocol .call the Nurse Practitioner or Wound Care Doctor .start an order .then make sure th… | 2020-09-01 |
| 1886 | 1886 | HILLCREST HEALTHCARE CENTER | 445316 | 111 E PEMBERTON STREET | ASHLAND CITY | TN | 37015 | 2019-05-21 | 689 | D | 0 | 1 | UFDY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow interventions for the prevention of accidents for 1 of 2 (Resident #7) sampled residents reviewed for accidents. The findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 13, which indicated no cognitive impairment, no behaviors, and was totally dependent on staff for transfers. The Care Plan dated 11/13/17, and last reviewed 4/28/19, documented, .risk for weakness, fatigue, malaise, lethargy r/t (related to) [MEDICAL CONDITION] .Interventions .If I experience any .bruising, or excessive bleeding alert my CN (Charge Nurse)/MD (Medical Doctor) .have impaired visual function .severely limited acuity .ADL (Activities of Daily Living) Self Care Performance Deficit r/t Debility, Stroke, [MEDICAL CONDITION] .have a right above the knee amputation .Transfers: 2 (staff) with hoyer . The incident report dated 5/8/19 and revised 5/10/19 documented, .CNA (Certified Nursing Assistant) approached this nurse and said that when they got (Resident #7) in lift, res (resident) bent forward and hit head on lift. After looking at res head, this nurse noted a half dime sized bruise on (L) (left) side of forehead .Immediate Action Taken .Have therapy review transfer practice . Observations in Resident #7's room on 5/19/19 at 12:12 PM, 5/20/19 at 9:11 AM, and 5/21/19 at 11:57 AM, revealed Resident #7 seated in her wheelchair with a lift pad underneath her, right leg amputation above the knee, and a large purplish bruise to the left side of her forehead that was approximately 3 centimeters in diameter. Interview with Occupational Therapist (OT) #1 on 5/20/19 at 4:04 PM, in the Staff Development Room, OT #1 was asked if she had reviewed the transfer practice for Resident #7. OT #1 stated, They had men… | 2020-09-01 |
| 1887 | 1887 | HILLCREST HEALTHCARE CENTER | 445316 | 111 E PEMBERTON STREET | ASHLAND CITY | TN | 37015 | 2019-05-21 | 880 | D | 0 | 1 | UFDY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 1 (Certified Nursing Assistant (CNA) #1) staff member failed to perform hand hygiene during indwelling catheter care. The findings include: The facility's undated Standard and Precaution Policy documented, .Hand Hygiene .before applying and after removing personal protective equipment, including gloves .before and after handling clean or soiled .linens . Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Foley cath (catheter) care q (every) shift .as needed . Observations in Resident #22's room on 5/21/19 at 9:01 AM, revealed CNA #1 gathered supplies, donned gloves, and completed indwelling catheter care. CNA #1 did not remove her gloves or wash her hands. CNA #1 completed incontinence care, and the wash cloth was noted with a moderate amount of dark brown substance. CNA #1 did not remove her gloves or wash her hands. CNA #1 applied barrier cream to Resident #22's buttock and assisted Resident #22 back to her wheelchair using the same gloved hands. CNA #1 then removed her gloves. Interview with CNA #1 on 5/21/19 at 9:20 AM, at the Nurses' Station, CNA #1 was asked if she should have removed her gloves and washed her hands between indwelling catheter care and incontinence care. CNA #1 stated, Yes. CNA #1 was asked if she should have removed her gloves and washed her hands between incontinence care and before applying barrier cream. CNA #1 stated, Yes, I should have put on new gloves. CNA #1 was asked if she should have removed gloves and washed her hands before assisting the resident back to her wheelchair. CNA #1 stated, Yes, I should .it's contamination. Interview with the Director of Nursing (DON) on 5/21/19 at 11:42 AM, at the Nurses' Station, the DON was asked when… | 2020-09-01 |
| 1888 | 1888 | HILLCREST HEALTHCARE CENTER | 445316 | 111 E PEMBERTON STREET | ASHLAND CITY | TN | 37015 | 2017-08-10 | 224 | K | 1 | 1 | D1L611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, and interview, the facility failed to prevent neglect by failing to provide the services necessary to avoid physical harm for residents utilizing electrical power strips for 1 resident (#87); failed to prevent neglect by failing to ensure the facility utilized approved electrical power strips for 14 residents (#87, #70, #22, #29, #91, #88, #65, #49, #16, #1, #12, #15, #24, #47) of 70 residents in the facility; and failed to prevent neglect by failing to prevent exploitation of 5 residents (#22, #26, #30, #49, #91) of 14 residents reviewed for abuse. The facility's system failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death) for Resident #87. The Administrator was notified of the Immediate Jeopardy on 8/10/17 at 1:00 PM in the Administrator's office. The facility's failure at F-224 represents Substandard Quality of Care. The findings included: Review of facility policy, Abuse, Neglect, and Exploitation/Dementia Management, revised 6/14/17 revealed .'Neglect' means failure of the facility .to provide goods and services to a resident that are necessary to avoid physical harm .The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including but not limited to the following possible indicators: Evidence of photographs or videos of a resident regardless of whether the resident provided consent and regardless of the resident's cognitive status . Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired, required extensive assistance of 2 or more people for bed mobility, dressing, toileting, and personal hygiene, was dependent with assistance o… | 2020-09-01 |
| 1889 | 1889 | HILLCREST HEALTHCARE CENTER | 445316 | 111 E PEMBERTON STREET | ASHLAND CITY | TN | 37015 | 2017-08-10 | 225 | E | 1 | 1 | D1L611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility investigations, and interview, the facility failed to thoroughly investigate an allegation of abuse for Resident #120 and failed to timely report allegations of abuse for 3 residents (#119, #120, #16), and for 1 resident (#24) injury of unknown origin of 14 residents reviewed for abuse or injury injury of unknown origin. The findings included: Medical record review revealed Resident #120 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation revealed the following: On 8/27/16 Resident #120 slapped Resident #57 on the face. On 8/31/16 Resident # 120 slapped Resident #57 on the face. Continued review revealed a guest/visitor witness statement dated 8/27/16 revealed the incident happened in the dining room. There were no witness statements for the 8/31/16 incident. Interview with the Administrator on 8/8/17 at 9:44 AM in the Administrator's office confirmed there were 2 instances of Resident #120 slapping Resident #57. Continued interview revealed the first instance was on 8/27/16 and the second instance was on 8/31/16; both incidents were reported to the State Agency in the same report on 9/2/16. Further interview revealed there was one witness statement documented on 8/27/16 by a visitor and there were no witness statements documented on 8/31/16. Continued interview confirmed the facility failed to report the alleged abuse in the required 24 hour time period for (YEAR) to the State Agency and the facility failed to thoroughly investigate the incident on 8/31/16. Medical record review revealed Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation revealed the resident reported the allegation of staff to resident verbal abuse, to the facility staff on 8/21/16 at 11:30 PM and the allegation was reported to the Administrator on 8/22/16 at 9:00 AM. Further review revealed the facility st… | 2020-09-01 |
| 1890 | 1890 | HILLCREST HEALTHCARE CENTER | 445316 | 111 E PEMBERTON STREET | ASHLAND CITY | TN | 37015 | 2017-08-10 | 253 | E | 1 | 1 | D1L611 | > Based on observation and interview, the facility failed to maintain 1 central bath (E-F hall) for 1 of 2 central baths in a safe and sanitary manner and for 1 random resident bathroom (301) of 46 resident rooms in a safe and sanitary manner. The findings included: Observations on 8/7/17 at 9:30 AM and 8/8/17 at 3:41 PM in the E-F central bath revealed 3 missing baseboard tiles on the wall to the right side of the bathtub. The missing tiles exposed the wet and blackened wooden wall studs. Continued observation revealed a commode chair beside the bathtub with black debris under the commode seat. Continued observation revealed two broken baseboard tiles located on the left side of the sink, 1 missing baseboard tile located to the left of the shower, and 1 cracked baseboard tile located under the wall socket and to the right of the bathtub. Further observation revealed multiple areas of peeling paint on all the walls. Continued observation revealed the railings of the permanent commode had dirty, gray and black stains on the straps. Observation on 8/8/17 at 8:02 AM in the bathroom of room 301 revealed peeling paint on the wall between the toilet paper holder and the shower. Interview with the Maintenance Director on 8/8/17 at 2:20 PM at the nurse's station revealed he was unaware the central bath needed repair and the facility had no specific procedure for informing maintenance of items needing repair. Continued interview confirmed the facility failed to repair the missing baseboard tiles in the E-F central bath. Interview with the Administrator on 8/8/17 at 4:25 PM at the nurse's station revealed the condition of the central bath has not been reported to me and that she would observe the bath when it was not in use. Interview with the Administrator on 8/8/17 at 5:20 PM in the E-F central bath confirmed 5 missing baseboard tiles, peeling paint to all walls, missing dry wall, 1 cracked base board tile, a penetrated, blackened wall where baseboard tiles were missing, and the dirty commode straps. The Administrator co… | 2020-09-01 |
| 1891 | 1891 | HILLCREST HEALTHCARE CENTER | 445316 | 111 E PEMBERTON STREET | ASHLAND CITY | TN | 37015 | 2017-08-10 | 257 | E | 0 | 1 | D1L611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of the daily maintenance log, medical record review, observation, and interview, the facility failed to maintain comfortable and safe temperatures in the dining area and in 4 of 6 halls (halls A, B, E, and F) for 3 residents (#21, #24, #80) of 49 residents reviewed. The findings included: Review of the facility policy, Maintaining Facility Temperature, dated 5/12/15 revealed .It is the policy .to maintain a temperature of 72 degrees to 78 degrees throughout the building . Review of the Daily Maintenance Log for the week of 8/7/17 revealed check marks on the temperature line corresponding with the day of the week, however, there was no documentation of the actual temperature reading on the specific days. Medical record review revealed Resident #21 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident # 21 had a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Observations on 8/9/17 at 7:55 AM and 8/10/17 at 8:16 AM on the A, B, [NAME] and F halls revealed the thermostat on A hall was set at 68 degrees Fahrenheit (F) and the temperature was 68 degrees F; the thermostat on B hall was set at 68 degrees F and the temperature was 68 degrees F; the thermostat on [NAME] hall was set on 70 degrees F; and the thermostat on F hall was set at 70 degrees F, and the temperature was 70 degrees F. Observation on 8/10/17 at 8:00 AM in the dining room revealed Resident #21 sitting at the table wearing a [NAME]et. Continued observation revealed the thermostat in the dining room was set at 69 degrees F and the temperature was 69 degrees F. Interview with Resident #21 on 8/10/17 at 8:00 AM in the dining room revealed the dining area was frequently cold when the weather was cold. Continued interview revealed other common areas in the facility were often cold. Medical … | 2020-09-01 |
| 1892 | 1892 | HILLCREST HEALTHCARE CENTER | 445316 | 111 E PEMBERTON STREET | ASHLAND CITY | TN | 37015 | 2017-08-10 | 278 | E | 0 | 1 | D1L611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and observation, the facility failed to accurately assess the medications administered for 2 residents (#40, #60); and failed to accurately assess the hospice status for 1 resident (#61); and failed to accurately assess the functional range of motion status for 1 resident (#87) of 49 residents Minimum Data Sets (MDS) reviewed. The findings included: Medical record review revealed Resident #40 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED]. Medical record review of the 14 day MDS dated [DATE] revealed Resident #40 was assessed to have been administered antibiotic medication and diuretic medication for 7 of 7 days of the review period. Interview with the MDS Coordinator/Registered Nurse (RN) #3 on [DATE] at 2:53 PM in her office confirmed the facility failed to accurately assess Resident #40's medications on the [DATE] MDS. Further interview confirmed no antibiotic or diuretic medication were ordered during the MDS review period. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30 day MDS dated [DATE] revealed Resident #60 had not been administered an anticoagulant medication during the review period. Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] Medical record review of the (MONTH) (YEAR) Physician order [REDACTED]. Interview with the MDS Coordinator/RN #3 on [DATE] at 10:10 AM in her office confirmed the [DATE] MDS failed to accurately assess the 7 of 7 days of anticoagulant administration. Medical record review revealed Resident #61 was admitted to the facility on [DATE], readmitted on [DATE] and expired on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].hospice. (Diagnosis) of Myelodysplasti[DIAGNOSES REDACTED] . Medical record review of a Significant C… | 2020-09-01 |
| 1893 | 1893 | HILLCREST HEALTHCARE CENTER | 445316 | 111 E PEMBERTON STREET | ASHLAND CITY | TN | 37015 | 2017-08-10 | 279 | D | 0 | 1 | D1L611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to develop a comprehensive care plan for 2 residents (#60, #64) of 49 residents reviewed. The findings included: Review of facility policy, Care Planning, revised 4/21/17 revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial need that are identified in the resident's comprehensive assessment .The comprehensive care plan will describe .The services to be furnished to attain or maintain resident's highest practicable physical, mental and psychosocial well-being . Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #60 had been administered anti-psychotic and anti-anxiety medication for 7 days each during the MDS review period. Further review revealed Resident #60 exhibited no [MEDICAL CONDITIONS] or behaviors and was down/depressed 0-1 day during the review period. Medical record review of the (MONTH) (YEAR) Physician order [REDACTED]. 1.) [MEDICATION NAME] (anti-psychotic medication) Tablet 100 milligrams (mg) Give 1 tablet by mouth at bedtime. 2.) On 6/23/17 [MEDICATION NAME] (anti-anxiety mediation) Tablet 0.5 mg. Give 0.5 mg by mouth every 12 hours as needed was ordered. Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] 1.) [MEDICATION NAME] was administered daily. 2.) [MEDICATION NAME] - as needed was not administered in (MONTH) (YEAR). Review of the Care Plan dated 6/1/17, updated 6/2/17 and 6/20/17 revealed the anti-psychotic and anti-anxiety medications, and possible side effects were not addressed. Interview with the MDS Coordinator/Registered … | 2020-09-01 |
| 1894 | 1894 | HILLCREST HEALTHCARE CENTER | 445316 | 111 E PEMBERTON STREET | ASHLAND CITY | TN | 37015 | 2017-08-10 | 280 | D | 0 | 1 | D1L611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility incident review, and interview, the facility failed to update the Care Plan for 2 residents (#61, #87) of 49 resident Care Plans reviewed. The findings included: Review of facility policy, Care Planning, revised [DATE] revealed, The comprehensive care plan will be reviewed and revised by the IDT (Interdisciplinary Team) after each comprehensive and quarterly assessment .Alternative interventions will be documented, as needed .staff responsible for carrying out the interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially, and when changes are made . Medical record review revealed Resident #61 was admitted to the facility on [DATE], readmitted on [DATE] and expired on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Comprehensive Care Plan revealed a focus for Falls with the .created dated [DATE] . Review of Facility Fall Incident Report dated [DATE] at 11:40 PM revealed a Certified Nurse Aide (CNA) notified the nurse that she observed the resident on the fall mat, sitting on his buttocks with his back against the bed, and his legs stretched out toward the bathroom. The revised intervention was, Walker to be placed by bed at all times open and ready for use. Review of Incident Investigation Form Management Review dated [DATE] revealed the new intervention was My walker will be placed next to bed open and ready for use when I am in bed. It was signed by Licensed Practical Nurse (LPN) #7, Registered Nurse (RN) #1 and #3, and the Director of Nursing (DON). Medical record review of the Comprehensive Care Plan with a focus for Falls dated [DATE] revealed no intervention to place a walker at the bedside open and ready to use after the [DATE] fall. Interview with the DON on [DATE] at 11:30 AM in the DON's office confirmed the facility failed to update the Care Plan after the fall on [DATE] wi… | 2020-09-01 |
| 1895 | 1895 | HILLCREST HEALTHCARE CENTER | 445316 | 111 E PEMBERTON STREET | ASHLAND CITY | TN | 37015 | 2017-08-10 | 281 | D | 0 | 1 | D1L611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of drugs.com for the standard, medical record review, observation, and interview, the facility failed to follow physician's orders [REDACTED].#82) of 7 residents observed for medication administration. The findings included: Review of facility policy, Medication Administration, dated 10/17/16 revealed .NuScript RX (prescription) Policy and Procedure Book .Medications are administered in accordance with written order of the attending physician . Review of www.drugs.com for the standard addressing the administration of Tamsulosin revealed the medication administration was to be .approximately 30 minutes after a meal . Medical record review revealed Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED].Administer approx. (approximately) 30 minutes after food . Observation during medication administration on 8/7/17 at 8:04 PM in Resident #82's room revealed Licensed Practical Nurse (LPN) #9 administering Tamsulosin HCL 0.4 mg by mouth to Resident #82. Interview with Resident #82 on 8/7/17 at 8:45 PM in his room revealed the resident stated he usually got his medications about the same time each night. Continued interview revealed when asked if he had eaten a snack prior to taking his medications earlier that evening he stated No. The last time I ate anything was at dinner time around 5:30 (PM) tonight. Interview with LPN #9 on 8/7/17 at 8:49 PM at the B hall medication cart revealed when asked about the order for Tamsulosin HCL to be given approximately 30 minutes after food, she stated He eats on days before we come in. Continued interview revealed when asked if a snack was offered prior to medication administration she replied No. Interview with LPN #8 on 8/7/17 at 8:51 PM at the B hall medication cart revealed when asked what time B hall dinner trays were served to residents, the LPN confirmed dinner trays came out ab… | 2020-09-01 |
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CREATE TABLE [cms_TN] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );