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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1757 | 1757 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2020-02-20 | 761 | E | 0 | 1 | VY3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to dispose of expired medications and supplies in 2 medication storage rooms (South Wing and West Wing) of 3 medication storage rooms observed. The findings include: Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biological, Syringes and Needles, revised 4/5/2019, showed .Facility should destroy or return all .outdated/expired .medications .Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis . During an observation of the South wing medication storage room and interview with Licensed Practical Nurse (LPN) #1 on 2/20/2020 at 9:42 AM, showed 7 wound culture swabs with an expiration date of 12/27/2019, 98 urine chemistry test strips (used to test the urine for possible infection) with an expiration date of 12/31/2019, and 5 unopened 5 milliliter vials of influenza vaccine with an expiration date of 5/31/2019. LPN #1 confirmed the above items were expired and were available for resident use. Observation of the West wing medication storage room and interview with LPN #2 on 2/20/2020 at 10:14 AM showed 4 [MEDICAL CONDITION] flanges (device used to hold a [MEDICAL CONDITION] bag) with an expiration date of 12/2018, 100 [MEDICATION NAME] plastic cannulas (needle free device used with intravenous injections) with an expiration date of 12/2019, and 42 [MEDICATION NAME] syringes with an expiration date of 4/2019. LPN #2 confirmed all above items were expired and were available for resident use. During an interview on 2/20/2020 at 10:27 AM the Director of Nursing stated it is his expectation for the medication storage rooms to be checked routinely and for all expired items to be discarded immediately. | 2020-09-01 |
| 1758 | 1758 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2020-02-20 | 770 | D | 0 | 1 | VY3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to obtain laboratory tests as ordered by the physician for 1 resident (Resident #37) of 5 residents reviewed for laboratory tests. The findings include: Review of the facility's policy titled, Diagnostic Services, last reviewed 4/15/2019, showed .Ensure that the residents receive laboratory .services as ordered by the attending physician . Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].for Hgb A1C (Glycated Hemoglobin, a laboratory test used to measure blood sugar) .every 6 month(s) .starting on the 17th (6/17/2020) Lipid panel (a laboratory test used to measure cholesterol level) .every 6 month(s) .starting on the 17th .TSH (a laboratory test to measure the [MEDICAL CONDITION] stimulating hormone) Free T3 (a laboratory test to measure [MEDICAL CONDITION] hormones) .every 6 month(s) .starting on 6/17/2019 . Review of Resident #37's medical record showed no documentation the Hgb A1C, the Lipid panel, the TSH level, or the Free T3 was completed on 6/17/2019. Further review revealed no documentation the Lipid panel or the Free T3 was completed on 12/17/2019. During an interview and review of the medical record on 2/19/2020 at 1:10 PM, Licensed Practical Nurse #3 confirmed the laboratory tests were not done. During an interview on 2/19/2020 at 1:15 PM, the Assistant Director of Nursing confirmed the laboratory tests were not done. | 2020-09-01 |
| 1759 | 1759 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2020-02-20 | 921 | D | 0 | 1 | VY3J11 | Based on facility policy review, observation and interview, the facility failed to provide a safe environment for residents on 1 hall (North hall) of 3 halls observed in the facility. The findings include: Review of the facility's policy, Maintenance, not dated, stated .The facility must provide a safe, functional, sanitary, and comfortable environment for the residents .The facility must: Equip corridors with firmly secured handrails . Observations made during the survey on 2/18/2020 through 2/20/2020 showed a partially detached handrail with 4 screws visibly exposed on the North hall. During an interview on 2/20/2020 at 11:17 AM, the Maintenance Director stated he first became aware of the partially detached handrail on the morning of 2/18/2020 and was aware the handrail was a safety hazard. During an interview on 2/20/2020 at 11:31 AM, Certified Nursing Assistant #1 stated there was 1 ambulatory resident and 11 residents who self-propelled in a wheelchair on the North hall who used the handrails. | 2020-09-01 |
| 1760 | 1760 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2018-02-28 | 609 | D | 1 | 1 | DRQP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, medical record review, observation, and interview, the facility failed to report an allegation of verbal abuse timely for 1 resident (#367) of 27 residents reviewed. The findings included: Review of the facility policy, Reporting Alleged Abuse, revised 2/1/17, revealed .Federal requirements mandate that facilities must ensure all allegations of abuse, neglect, exploitation, or mistreatment are reported immediately to their state survey agency .Failure to do so will mean that the facility is not in compliance with the federal regulations .when an incident of resident abuse is suspected .The administrator, director of nursing, or designated representative will complete an investigation . Medical record review revealed Resident #367 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set admission assessment dated [DATE] revealed resident #367's Brief Interview for Mental Status score was 15 of 15 indicating the resident was cognitively intact. Observation and interview with Resident #367 on 2/26/18 at 11:30 AM, in her room, revealed the resident voiced a complaint of verbal abuse. Further interview revealed Resident #367 stated, About a month ago a girl came into my room one night and told me all I do is pee and poop and lay up in the bed like a white woman wanting my butt wiped. Continued interview revealed the resident believed the girl was an employee of the facility, and was African-American, tall with a medium build, and short bright red hair. Further interview revealed Resident #367 had reported the incident to someone at the facility but could not remember who. Review of a facility Witness Statement Form dated 12/21/17 with a time of 11:35 AM, revealed .she says I poop and pee too much. She says I lay in the bed and want my butt wiped like white folks .Do you feel like you are being abused by her? Not physically. She just says very unpleasant … | 2020-09-01 |
| 1761 | 1761 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2018-02-28 | 610 | D | 1 | 1 | DRQP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, medical record review, observation, and interview, the facility failed to conduct an investigation for an allegation of verbal abuse for 1 resident (#367) of 27 residents reviewed. The findings included: Review of the facility policy, Reporting Alleged Abuse, revised 2/1/17 revealed .Federal requirements mandate that facilities must ensure all allegations of abuse, neglect, exploitation, or mistreatment are reported immediately to their state survey agency .Failure to do so will mean that the facility is not in compliance with the federal regulations .when an incident of resident abuse is suspected .The administrator, director of nursing, or designated representative will complete an investigation . Medical record review revealed Resident #367 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set admission assessment dated [DATE] revealed resident #367's Brief Interview for Mental Status score was 15 out of 15 indicating the resident was cognitively intact. Observation and interview with Resident #367 on 2/26/18 at 11:30 AM, in her room, revealed the resident voiced a complaint of verbal abuse. Further interview revealed Resident #367 stated about a month ago there was a girl came in my room one night and told me all I do is pee and poop and lay up in the bed like a white woman wanting my butt wiped. Continued interview revealed the girl was an employee of the facility and was African-American, tall with a medium build, and short bright red hair. Further interview revealed Resident #367 had reported the incident to someone at the facility but could not remember who. Review of a facility Witness Statement Form dated 12/21/17 with a time of 11:35 AM, revealed .she says I poop and pee too much. She says I lay in the bed and want my butt wiped like a white folks .Do you feel like you are being abused by her? Not physically. She just says very unpleas… | 2020-09-01 |
| 1762 | 1762 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2017-10-18 | 225 | D | 1 | 0 | 71FX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interviews, the facility staff failed to report an allegation of abuse timely for 1 resident (#3) of 5 residents reviewed for abuse of 6 sampled residents. Review of facility policy, Reporting Alleged Abuse, dated 2/7/17 revealed .Facilities must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but not later than 2 hours after the allegation is made . Resident #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 1 (severe cognitive impairment). Continued review revealed the resident required extensive assist with transfers, dressing, eating, and personal hygiene with 1 person assist. Further review revealed the resident was always incontinent of bowel and bladder. Review of a facility investigation dated 6/22/17 revealed Certified Nurse Assistant (CNA) #12 alleged she observed CNA #13 abuse Resident #3 while providing personal care on 6/20/17. Continued review revealed the facility was not notified of the alleged incident until 6/22/17 (2 days later). Interview with CNA #10 on 10/18/17 at 1:30 PM, in the conference room, revealed .told her (CNA #12) .she needed to fill out a witness statement and give it to the charge nurse . Telephone interview with CNA #12 on 10/23/17 at 10:30 AM revealed .I was new .had only been there a couple of weeks .wasn't sure what I needed to do .asked someone and they told me to fill out a paper and give to the supervisor or Director of Nursing .He was not there that day or the next .got in trouble because I didn't report it sooner . Interview with the Administrator and the Director of Nursing on 10/18/17 at 3:15 PM, in the conference room, confirmed the facility failed to report an allegat… | 2020-09-01 |
| 5388 | 5388 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2016-01-27 | 225 | D | 0 | 1 | KVD311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to complete an abuse investigation for 1 resident (#129) of 7 residents reviewed. The findings included: Review of facility policy, Abuse and/or Neglect Investigation, revised 2/2009 revealed .interviews with any witnesses to the incident .interviews with staff members on all shifts having contact with the resident at the time of the incident .interviews with the resident's roommate . Resident #129 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change Minimum (MDS) data set [DATE] revealed a Brief Interview Mental Status score of 00 (severe cognitive impairment) and required extensive assist for toileting, dressing, and transfer. Medical record review of the facility investigation dated 8/27/15 revealed Resident #129 reported to staff .sometime during the night 2 female and 1 male staff members came into her room and began beating her up . Further review of the Witness Interview Form revealed 1 staff interview of 18 direct staff on duty during the time of the alleged abuse. Continued review revealed no interview with Resident #129's roommate. Interview with the Administrator, the Director of Nursing (DON), and the Assistant Director of Nursing on 1/27/16 at 11:55 AM, in the DON's office confirmed the facility failed to complete a through investigation for an allegation of abuse. | 2019-03-01 |
| 5389 | 5389 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2016-01-27 | 323 | D | 0 | 1 | KVD311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation, and interview, the facility failed to implement a new intervention after a fall for 1 resident (#157) of 3 residents reviewed for falls of a total of 33 residents sampled. The findings included: Review of facility policy, Falls Management, (not dated) revealed .The charge nurse will .communicate fall reduction interventions to care givers on the unit and in shift report . Medical record review revealed Resident #157 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation dated 7/19/15 revealed no documentation of a new intervention after a fall. Medical record review of a Nurse's note dated 7/19/15 revealed .pt (patient) in front of nurse's station attempted to sit down in wheelchair and fell and hit her head on side of wall .ice applied. Patient is alert able to make needs known, neuro check WNL (within normal limit) . Continued medical record review of the fall revealed no documentation of a new intervention after the 7/19/15 fall. Interview with the Director of Nursing (DON) on 1/27/16 at 10:45 AM, in the DON's office confirmed no new intervention had been put in place after the 7/19/15 fall. | 2019-03-01 |
| 5390 | 5390 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2016-01-27 | 364 | D | 0 | 1 | KVD311 | Based on facility policy review, observation, and interview, the facility failed to properly maintain food temperatures at a palatable level upon delivery to residents for 1 of 3 hallways reviewed. The findings included: Review of facility policy, Food Temperature Control, dated 1/01/07 revealed .Food temperatures are maintained during serving times to ensure residents receive safe food served at acceptable temperatures .Hot foods are held at a minimum of 140 F (Fahrenheit) or higher and cold foods at or below 40 F or per state requirements . Observation with the Dietary Manager (DM) on 1/26/16 at 8:58 AM, on the north hallway confirmed the following test tray temperature results: -Whole milk 45 degrees F. -Oatmeal 122 degrees F. -Scrambled eggs 120 degrees F. -Biscuit covered with gravy 110 degrees F. -Turkey sausage 85 degrees F. Interview with the DM on 1/26/16 at 9:16 AM, on the north hallway confirmed the facility failed to ensure proper temperature of food trays on the food cart on 1 of 3 hallways observed. | 2019-03-01 |
| 7177 | 7177 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2014-12-10 | 247 | D | 0 | 1 | X78U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure residents were informed prior to a room change for two residents (#19 and #139) of twenty-six residents reviewed. The findings included: Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #139 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Interview with resident #139 on December 8, 2014, at 2:11 p.m., in the resident room, revealed the resident had a room change in the last nine months, and was not notified prior to a change of rooms. Interview with resident #19 on December 9, 2014, at 8:42 a.m., in the resident room, revealed the resident had a room change in the last nine months, and was not notified prior to a change of rooms. Review of the facility policy Resident Room Relocation revealed, .resident's ability to cope and adjust to the relocation are adressed by taking the following steps .1. Providing the resident, legal guardian and interested family member with a verbal notice and documenting this in the medical record . Interview with the Social Services Director and medical record review, on December 10, 2014, at 8:24 a.m., at the 300 hall nurse's station, confirmed there was no documentation the family or resident was notified of the room changes prior to the room change. | 2018-03-01 |
| 7178 | 7178 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2014-12-10 | 371 | F | 0 | 1 | X78U11 | Based on observation and interview, the facility failed to store five of five storage containers and failed to store dishes in a sanitary manner in one of one plate warmer racks. The findings included: Observation on December 8, 2014, at 10:00 a.m., with the Dietary Manager (DM) in the facility kitchen, revealed five white storage containers (approximately 2 quart size) stacked, the inside of each container was wet, and the containers were stored and ready for use. Interview with the DM on December 8, 2014, at10:00 a.m., in the facility kitchen, confirmed the five containers were stacked wet and ready for use to serve resident food. Observation on December 8, 2014, at 10:15 a.m., with the DM in the facility kitchen, revealed a two sided plate warmer rack, with food debris on both plate platforms. Continued observation revealed approximately twenty plates stored in the left side, and ready for use to serve the residents' lunch. Interview with the DM on December 8, 2014, at 10:20 a.m., in the facility kitchen, confirmed both plate platforms of the plate warmer rack were soiled with food debris, and the twenty plates stored on the left side were ready for use to serve residents food. Observation on December 8, 2014, at 11:55 a.m., in the facility kitchen, revealed the plate warmer platforms still had food debris, and the staff used the plates in the plate warmer to serve the residents lunch. Observation on December 10, 2014, at 12:45 p.m., with the DM in the facility kitchen, revealed both plate platforms in the plate warmer had food debris. Continued observation revealed approximately twenty plates in the left side ready for use to serve the residents' lunch. Interview with the DM on December 10, 2014, at 12:57 p.m., in the facility kitchen, revealed the plate warmer rack was scheduled to be cleaned daily. Continued interview confirmed both plate platforms in the plate warmer had food debris, the plates in the left side were ready for use to serve residents food, and the plate warmer had not been cleaned for two da… | 2018-03-01 |
| 8104 | 8104 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2014-08-19 | 157 | D | 1 | 0 | NYAF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation, observation, and interview, the facility failed to ensure the Physician was notified insulin was unavailable for administration as ordered for one resident (#1), and failed to notify the Responsible Party of a fall for one resident (#6) of nine residents reviewed. The findings included: Resident #1 was readmitted to the facility on [DATE], at 7:00 p.m., with [DIAGNOSES REDACTED]. The resident discharged Against Medical Advice (AMA) on February 11, 2014. Medical record review of a physician's orders [REDACTED].m . Continued review revealed the amount of Humalog units to be administered was based upon finger-stick blood-glucose (FSBG) results obtained at the identified times, QID, as follows: FSBG FSBG 150-199; administer 2 units FSBG 200-249; administer 5 units FSBG 250-299; administer 7 units FSBG 300-349; administer 10 units FSBG 350-400; administer 12 units FSBG > (greater than) 400; administer 15 units and call Physician Medical record review of resident #1's February 2014 Medication Administration Records (MAR's) revealed on February 10, 2014, at 8:00 p.m., the resident's (HS) FSBG was 193 and required 2 (two) units of Humalog insulin. Continued review on the back of the MAR indicated [REDACTED] Continued review of the MAR's revealed the resident's FSBG had increased from 193 on February 10, 2014, at 8:00 p.m., to 221 on February 11, 2014, at 7:30 a.m., and received 5 (five) units of Humalog insulin, as ordered. Telephone interview with Licensed Practical Nurse (LPN) #1 on August 19, 2014, at 7:12 p.m., confirmed LPN #1 obtained resident #1's FSBG on February 10, 2014, at 8:00 p.m., and the Humalog insulin was not available to administer the ordered 2 (two) units of insulin. Continued interview confirmed the nurse had failed to notify the Physician the Humalog insulin was unavailable for administration, as ordered. Interview with the Director of Nursing (DON) in the DON's o… | 2017-08-01 |
| 8105 | 8105 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2014-08-19 | 309 | D | 1 | 0 | NYAF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a Pharmacy Medication Request, review of Pharmacy Refill Medications History, review of a Pharmacy Proof of Delivery report, and interview, the facility failed to ensure insulin was administered as ordered for one resident (#1) and failed to ensure an inhaler was administerd as ordered for one resident (#6) of nine residents reviewed. The findings included: Resident #1 was readmitted to the facility on [DATE], at 7:00 p.m., with [DIAGNOSES REDACTED]. The resident discharged Against Medical Advice (AMA) on February 11, 2014. Medical record review of a physician's orders [REDACTED].m . Continued review revealed the amount of Humalog units to be administered was based upon finger-stick blood-glucose (FSBG) results obtained at the identified times, QID, as follows: FSBG FSBG 150-199; administer 2 units FSBG 200-249; administer 5 units FSBG 250-299; administer 7 units FSBG 300-349; administer 10 units FSBG 350-400; administer 12 units FSBG > (greater than) 400; administer 15 units and call Physician Medical record review of resident #1's February 2014 Medication Administration Records (MAR's) revealed on February 10, 2014, at 8:00 p.m., the resident's HS FSBG was 193 and required 2 (two) units of Humalog insulin. Continued review on the back of the MAR indicated [REDACTED] Continued review of the MAR's revealed the resident's FSBG had increased from 193 on February 10, 2014, at 8:00 p.m., to 221 on February 11, 2014, at 7:30 a.m., and received 5 (five) units of Humalog insulin, as ordered. Review of a pharmacy medication request for the ordered Humalog insulin revealed the facility did not request the insulin from the Pharmacy until February 11, 2014, at 12:01 a.m. Telephone interview with Licensed Practical Nurse (LPN) #1 on August 19, 2014, at 7:12 p.m., confirmed LPN #1 obtained resident #1's FSBG on February 10, 2014, at 8:00 p.m., and the Humalog insulin was not available to administer the ordered 2 (… | 2017-08-01 |
| 8106 | 8106 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2014-08-19 | 425 | D | 1 | 0 | NYAF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of pharmacy reports, review of pharmacy protocols, observation, and interview, the facility failed to ensure the Pharmacy provided medications in a timely manner to administer for one resident (#6) of nine residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set (MDS) dated [DATE], revealed resident #6's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS) score of eight, with fifteen being the highest possible score. Medical record review of the July 2014 Physician's Recapitulation Orders revealed, .Flovent 44 mcg (micrograms)/ (per) actuation (compression of the inhaler) aerosol inhaler .BID (twice daily) .at 8:00 a.m., and 8:00 p.m . Medical record review of the July 2014 Medication Administration Records (MAR's) revealed the Flovent inhaler was not administered on July 9 at 8:00 p.m., and July 10 at 8:00 a.m. Medical record review of the physician's orders [REDACTED]. Medical record review of the July 2014 Physician's Recapitulation Orders revealed, .Flovent 44 mcg (micrograms)/ (per) actuation (compression of the inhaler) aerosol inhaler .BID (twice daily) .at 8:00 a.m., and 8:00 p.m . Review of a Pharmacy Refill Medications History report dated July 5 through July 10, 2014, revealed the facility requested a refill for the Flovent on Sunday, July 6, 2014, at 5:49 p.m. Continued review revealed a second request for a refill was placed on Tuesday, July 8, 2014, at 12:47 p.m. Further review of the report revealed refill request received by the Pharmacy for both refill requests submitted by the facility. Review of a Pharmacy Proof of Delivery report dated July 9 through July 11, 2014, revealed the facility did not receive the Flovent until July 10, 2014, at 12:12 p.m. Review of the Pharmacy's Medication Refills protocol (no date) revealed, .Delivery Schedu… | 2017-08-01 |
| 9206 | 9206 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2013-11-06 | 280 | D | 0 | 1 | 5DXV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to revise a care plan for a Stage 2 pressure ulcer (a partial thickness loss of skin, presenting as a shallow pink or red open area) for one resident (#114) of three residents with pressure ulcers, of 35 residents reviewed. The findings included: Resident #114 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident had been assessed as being at risk for pressure ulcers and weekly skin assessments were being completed. Continued review revealed on October 14, 2013, the resident developed a Stage 2 pressure ulcer on the left buttock measuring 1.5 cm. (centimeter) x 0.8 cm. x 0.1cm. Physician orders [REDACTED]. Medical record review of the resident's current Care Plan revealed the care plan had not been revised/updated to address the Stage 2 pressure ulcer. Interview with Registered Nurse (RN) Supervisor at the 200 Hall Nursing Station, on November 6, 2013, at 8:15 a.m., confirmed the care plan had not been revised/updated to address the stage 2 pressure ulcer. | 2017-02-01 |
| 9207 | 9207 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2013-11-06 | 371 | F | 0 | 1 | 5DXV11 | Based on observation and interview, the facility failed to provide sanitary storage of food and equipment. The findings included: Observation of the dietary department on November 4, 2013, from 10:00 a.m. until 10:30 a.m., revealed: 1. Doors to the kitchen did not close completely; 2. Pitcher of juice in walk in cooler was undated, and available for use; 3. Thirty-six pound box of Turnips sitting on the floor of walk in freezer, and was available for use; 4. Two chicken breasts undated in walk in freezer, and were available for use; 5. Bag of sugar cookie cubes in the walk in freezer was opened and undated, and was available for use; 6. Bag of biscuits in the walk in freezer was opened and undated, and was available for use; 7. No thermometer was available in the milk cooler; 8. Five pound container of quick grits was opened and undated in the dry storage room, and was available for use; 9. Twenty-eight ounce container of wheat farris was opened and undated in the dry storage room, and was available for use; 10. Fourty-two ounce container of quick oats was opened and undated in the dry storage room, and was available for use; 11. Bag of fruit flavored round type cereal was opened and undated in the dry storage room, and was available for use; 12. Eight ounce bottle of dehydrated coffee was opened and undated in the dry storage room, and was available for use; 13. Thirty-two ounce bottle of lemon juice was opened and undated in the dry storage room, and was available for use; Interview with the Dietitian on November 4, 2013, at 10:30 a.m., in the dietary department, confirmed the doors to the kitchen should close completely, the juice pitcher should have been dated, no boxes were to be stored on the floor, food in the freezer should be closed and dated after being opened, there was no thermometer in the milk cooler, and all foods in the dry storage area should have been closed and dated after being opened. Continued observation of the dietary department on November 4, 2013, from 11:15 a.m. to 11:45 a.m., revealed:… | 2017-02-01 |
| 9208 | 9208 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2013-11-06 | 372 | D | 0 | 1 | 5DXV11 | Based on observation and interview, the facility failed to dispose of garbage and refuse properly to maintain sanitary conditions. The findings included: Observation of the garbage and refuse dumpster on November 4, 2013, from 10:00 a.m. until 10:15 a.m., revealed the garbage dumpster had two lids open with a half full dumpster of refuse. Further observation revealed refuse around the dumpster on the ground. This refuse included paper, cup lids, butter containers, and other types of kitchen refuse on the ground. Interview with the Dietitian on November 4, 2013, at 10:15 a.m., at the dumpster, confirmed the lids of the dumpster were not closed and refuse was not contained. | 2017-02-01 |
| 11343 | 11343 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2012-06-07 | 272 | D | 0 | 1 | H8BZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete an accurate comprehensive assessment for one (#200) of forty sampled residents reviewed. The findings included: Resident #200 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed on April 23, 2012, at 10:50 p.m., the resident sustained [REDACTED]. Review of the Minimum Data Set (MDS) fifteen day assessment dated [DATE], and the thirty day MDS assessment dated [DATE], revealed the MDS did not reflect the fall on April 23, 2012. Interview with MDS (Minimum Data Set ) Coordinator #1 in the MDS office on June 6, 2012, at 10:50 a.m., confirmed the completed MDS dated [DATE], and MDS dated [DATE], had been coded incorrectly and did not reflect the resident's fall. | 2016-02-01 |
| 11344 | 11344 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2012-06-07 | 280 | D | 0 | 1 | H8BZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to update the Care Plan to address weight loss for one resident (#45) of forty residents reviewed. The findings included: Resident #45 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had severe cognitive impairment, required extensive assistance with all activities of daily living, and weighed 138 pounds. Medical record review of the Care Plan dated February 16, 2012, revealed .(res) has some missing natural teeth .At risk for weight loss .Regular diet w/chopped meats, no sandwiches . Medical record review of the Weight Change History report dated January 1, 2012 through June 6, 2012 revealed .2/1/2012 137.80 (pounds); 3/2/12 138.60; 4/3/12 110.60; 4/6/12 110.6 .6/1/12 111.0 . Medical record review of a Nutrition Data Collection/assessment dated [DATE], revealed .current weight 110.6 .IBW (ideal body weight) 112 - 138 .significant wt change .add to NIP (Nutrition Intervention Program) to follow .no woulnds .unintended wt. (weight) loss r/t (related to) possible decrease po (oral intake) in evening .follow wkly (weekly) wts add to NIP .consider iron supplement after CBC (Complete Blood Count) this month .Rec (recommend) Ensure Pudding BID (twice a day) .placed on NP (nurse practitioner) board . Medical record review of the Care Plan revealed no new interventions or reccomendations by the Registered Dietician were added to the Care Plan until May 31, 2012. Interview with the Director of Nursing on June 7, 2012, at 10:10 a.m., in the conference room confirmed the Resident's care plan was not updated in April 2012 when the weight loss was noted. | 2016-02-01 |
| 11345 | 11345 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2012-06-07 | 311 | D | 0 | 1 | H8BZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure restorative nursing was provided for one (#125) of forty residents reviewed. The findings included: Resident #125 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].Restorative Nursing PT (physical therapy) .6 days wk (week) x 8 wks .ambulation/gait training, OT (occupational Therapy) .6 days wk for 4 wks .therapeutic exercises. Medical record review of the Nursing Rehabilitation/Restorative Care Daily Flow Sheet dated May 20, 2012, revealed Restorative Nursing had not been initiated until May 23, 2012 (6 day delay from date of order on May 17, 2012). Medical record review of the Nursing Rehabilitation/Restorative Care Daily Flow Sheet dated May 27, 2012, revealed the resident received Restorative Nursing on May 27, 2012, and not again until June 3, 2012. Interview on June 6, 2012, at 12:55 p.m. with the Director of Nursing, in the conference room, confirmed a delay in starting restorative nursing and restorative nursing had not been provided 6 days a week as ordered by the physician the week of May 27, 2012. | 2016-02-01 |
| 11346 | 11346 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2012-06-07 | 371 | F | 0 | 1 | H8BZ11 | Based on observation and interview, the facility failed to serve food to residents under sanitary conditions. The findings included: Observation on June 4, 2012, at 12:10 p.m., in the main dining room, revealed four staff members with uncontained shoulder length hair serving the noon meal to residents. Interview with the Registered Dietician on June 4, 2012, at 12:13 p.m., in the main dining room, confirmed the four staff members with uncontained long hair were serving residents under unsanitary conditions and their hair was to be contained. | 2016-02-01 |
| 11347 | 11347 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2012-06-07 | 441 | D | 0 | 1 | H8BZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, observation, and interview, the facility failed to maintain infection control for one random observation during a medication pass. The findings included: Observation on June 5, 2012, at 8:20 a.m., with Licensed Practical Nurse (LPN) #1 revealed LPN #1 administered [MEDICATION NAME] Insulin 3 units subcutaneous to the resident's left abdomen without wearing gloves. Review of facility policy, Subcutaneous Injection, revealed .Observe (standard) universal precautions or other infection control standards .wear gloves when appropriate . Interview on June 5, 2012, with LPN #1 confirmed gloves are to be worn when giving an injection. | 2016-02-01 |
| 11348 | 11348 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2012-06-07 | 502 | D | 0 | 1 | H8BZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain laboratory services as ordered for one resident (#45) of forty residents reviewed. The findings included: Resident #45 was readmitted to the facility November 18, 2010, with [DIAGNOSES REDACTED]. Medical record review of Physician order [REDACTED].CBC (complete blood count), CMP (complete metabolic profile) every 3 months (JAN/APR/JUL/OCT) 10/25/10 (date originally ordered) . Medical record review of the laboratory reports revealed a CBC and a CMP were completed in January 2012. Further medical record review revealed no documentation the labs for April 2012 were completed as ordered. Interview with the Nurse Consultant on June 6, 2012, at 3:45 p.m., at the 200 Hall Nurse's Station, confirmed the laboratory studies, CBC and CMP, were not completed as ordered in April 2012. | 2016-02-01 |
| 12520 | 12520 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2012-04-09 | 323 | J | 1 | 0 | R5QU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of the facility investigation, review of facility policy, and interview, the facility failed to provide supervision and the correct dining environment for one Resident (#10) of sixteen Residents reviewed. The facility's failure to ensure Resident #10 was placed in the correct dining environment with supervision resulted in the Resident choking and aspirating food, requiring emergency rescue measures, transfer to the hospital emergency room , and admission to the Critical Care Unit on [DATE], and death on [DATE]. The facility's failure placed Resident #10 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a Resident). The Administrator and Director of Nursing were informed of the Immediate Jeopardy in the Conference Room on [DATE], at 2:15 p.m. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment, with a score of three out of fifteen. A score of three revealed the Resident's cognition was severely impaired. Medical record review of the Physician's Recapitulation Orders dated [DATE] - 30, 2012, revealed orders for a mechanical soft diet and liquids in a two-handled cup. Observation of the Resident on [DATE], at approximately 1:05 p.m., in the West Day Room, revealed a meal tray was on a table directly in front of the Resident and the Resident was eating, independently and unsupervised. Continued observation at approximately 1:20 p.m., revealed the Resident was non-responsive to verbal stimuli, the body was limp, face was pale, and the lips were blue. The Resident's chest was still and then the mouth opened and closed, with a silent gasp. During the gasp a large amo… | 2015-08-01 |
| 12521 | 12521 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2012-07-25 | 323 | D | 1 | 0 | NSDZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility document review, interview, and observations, the facility failed to provide supervision to prevent accidents for one resident (#3) of seven residents reviewed. The findings included: Medical Record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS, a detailed assessment of the resident) dated May 21, 2012, revealed Resident #3 required extensive assist of one person for toilet use, personal hygiene, transfers, and ambulation. Further review of the MDS revealed the resident's balance was unsteady when standing. Review of Nurse's Notes dated June 23, 2012, at 7:30 a.m., revealed, "Resident was in bathroom washing...hands with CNA (Certified Nursing Assistant) present. CNA turned to get gerichair and resident fell back onto floor. No new injuries noted..." Interview with CNA #1, by telephone, on July 24, 2012, at 1:00 p.m., revealed CNA #1 was caring for Resident #3, when the fall occurred on June 23, 2012. CNA #1 stated the resident was standing at bathroom sinking washing hands, and the CNA turned away from the resident, walked "three to four" steps to the bathroom door to obtain the resident's gerichair. The CNA stated the resident fell on to the floor, while the CNA's was getting the gerichair. Interview with the Director of Nurses (DON) on July 24, 2012, at 1:30 p.m. confirmed the resident fell after being left unattended by the CNA on June 23, 2012. Observations on July 24, 2012, at 10:30 a.m., in the Physical Therapy department, revealed Resident #3 being ambulated with walker and assist of one therapist. | 2015-08-01 |
| 13486 | 13486 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2010-12-08 | 332 | D | 0 | 1 | GB7G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of manufacturer's specifications, and interview, the facility failed to prevent medication errors less than five percent resulting in three errors within forty-two opportunities to equal an error rate of seven percent. The findings included: Medication Error #1: Observation on December 6, 2010, at 3:40 p.m., at the North West Split Cart revealed RN #1 administered one [MEDICATION NAME] (medication for Diabetes) 1000 mg (milligram) tablet to Resident #23. Medical record review of the signed physician order [REDACTED].#23 revealed an order for [REDACTED]. Interview with RN #1 on December 6, 2010, at 4:30 p.m., at the North West Split Cart outside the room of Resident #23 confirmed one medication error occurred when the [MEDICATION NAME] 1000 mg tablet was administered 80 minutes before supper and not with supper per the physician's orders [REDACTED]. Interview with the Food Service Director on December 7, 2010, at 4:05 p.m., in the Dietary Service Office confirmed North Wing supper trays were served between 5:30 p.m., and 5:35 p.m. on December 6, 2010. Medication Error #2 Observation on December 6, 2010, at 3:40 p.m., at the North West Split Cart revealed RN #1 administered two puffs of [MEDICATION NAME] (oral inhaler for asthma) by mouth ad exited the resident's room. The [MEDICATION NAME] inhaler contained two medications ([MEDICATION NAME] (corticosteroid medication) 115 mcg (microgram) and Salmeterol (medication for the prevention of [MEDICATION NAME]) 21 mcg) per puff. Medical record review of a physician's orders [REDACTED].#23 revealed "[MEDICATION NAME]..115-21MCG (microgram) AER (aerosol)...INHALATIONS TAKE 2 PUFFS TWICE DAILY..." Review of the manufacturer's specifications in the package insert for [MEDICATION NAME] oral inhaler revealed "...Instructions for taking a dose from your [MEDICATION NAME] you finish taking this medicine, rinse your mouth with water. Spit out the water. Do … | 2014-12-01 |
| 13487 | 13487 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2010-12-08 | 428 | F | 0 | 1 | GB7G11 | Based on record review individual monthly medication regimen reviews, facility pharmacy policy, and interview, the facility failed to act upon 27 of 29 drug regimen reviews completed by the Consultant Pharmacist for the months of September 2010 and October 2010. The findings included: Record review of the individual (resident) monthly medication regimen reviews completed by the Consultant Pharmacist dated Sepetember 15, 2010, and September 17, 2010, in the Conference Room with the Director of Nursing (DON) revealed 19 of 20 recommendations for the month of September 2010 had not been acted upon. Further record review of the individual monthly medication regimen reviews dated October 20, 2010, revealed 8 of 9 recommendations by the Consultant Pharmacist for the month of October 2010 had not been acted upon. Review of facility pharmacy policy Medication Regimen Review revealed "...PROCEDURE...6. Facility should ensure that Facility Physicians/Prescribers are provided with copies of the MRRs (Medication Regimen Reviews). 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR. For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either (a) accept and act upon the recomnendations contained within the MRR, or (b) reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 8. Facility should provide the Medical Director with a copy of the MRRs and should alert the Medical Director where MRRs require follow-up. 9. Facility should maintain copies of MRRs on file in Facility, either as part of the resident's permanent medical record or in a special file..." Interview with the DON on December 8, 2010, at 2:20 p.m., in the Conference Room confirmed the facility failed to ensure 27 of 29 individual monthly drug regimen reviews completed by the Consultant Pharmacist for the… | 2014-12-01 |
| 13488 | 13488 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2010-12-08 | 431 | D | 0 | 1 | GB7G11 | Based on observation, record review, facility policy, and interview, the facility failed to ensure an account of all controlled drugs were maintained and periodically reconciled for two (North Wing Cart #1 and North Wing Cart #2) of six medication carts and one (Resident #6) of 26 twenty-six residents reviewed; and drugs were stored under proper temperature controls for two of three medication refrigerators. The findings included: North Wing Cart #1 Observation and review of the Individual Patient Narcotic Records with the Director of Nursing (DON) on December 6, 2010, at 11:10 a.m., during the North Wing Cart #1 controlled substance record audit revealed 43 Individual Patient's Controlled Substances Records in the North Wing narcotic notebook and 43 corresponding narcotic medications in the North Wing Cart #1 narcotic box. Further observation of the North Wing Cart #1 December 2010 Narcotic Count Verification Sheet revealed only 42 Individual Patient's Controlled Substances Records were reconciled with 42 corresponding narcotic medications on December 6, 2010, at 6 a.m., by LPN #4 (the incoming nurse on the 6 a.m., to 2 p.m., shift) with RN #2 (the offgoing nurse for the 10 p.m., to 6 a.m., shift). Record review of the North Wing Cart #1 Narcotic Count Verification sheet revealed "...Schedule drugs are to be counted at the beginning and the conclusion of each shift. The incoming nurse and the offgoing (nurse) must count both the number of drugs on each card, and the total number of cards and narcotic sheets...Any discrepancies are to be reported to the DON immediately. Neither associate can leave until count is corrected..." Interview with the DON on December 6, 2010, at 11:15 a.m., at the North Wing Cart #1 confirmed the Narcotic Count Verification Sheet reconciliation by LPN #4 (the incoming nurse on the 6 a.m., to 2 p.m., shift) with RN #2 (the offgoing nurse for the 10 p.m., to 6 a.m., shift) was incorrect on December 6, 2010, at 6:00 a.m., and the discrepancy had not been reported to the DON. North Wing Car… | 2014-12-01 |
| 13489 | 13489 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2010-12-08 | 226 | D | 1 | 1 | GB7G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility investigation, facility policy review, observation, and interview, the facility failed to implement the abuse policy after an allegation of abuse for one resident (#11) of twenty-six residents reviewed. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory deficits and severely impaired cognitive skills. Review of a facility investigation revealed Registered Nurse (RN) #3 had heard Resident #11 yelling on July 3, 2010, at sometime between 4:00 and 5:00 a.m., (exact time unknown). Continued review of the facility investigation revealed RN #3 entered resident #11's room and observed Certified Nursing Assistant (CNA) #1 and CNA #2 providing incontinence care to the resident. Continued review of the facility investigation revealed RN #3 had observed CNA #1 "hit across resident's mouth." Review of facility policy Managing Incidents of Alleged Abuse & Neglect revealed "...Provide protection...Separate the alleged perpetrator from the resident(s). If the perpetrator is a staff member, send the employee home pending investigation..." Observation on December 6, 2010, at 11:55 a.m., revealed the resident seated in a wheelchair at the side of the bed. Telephone interview on December 7, 2010, at 11:00 a.m., with RN #3 revealed RN #3 heard the resident yelling and entered the resident's room to investigate on July 3, 2010 at approximately 5:00 a.m. Continued interview revealed RN #3 observed CNA #1 and CNA #2 providing incontinence care to resident #11. Continued interview revealed RN #3 then observed CNA #1 slap the resident's mouth with a disposable incontinence wipe and state to the resident to hush. Continued interview revealed RN #3 did not intervene or confront CNA #1 but returned to the nursing station and called the unit ma… | 2014-12-01 |
| 13490 | 13490 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2010-12-08 | 371 | F | 0 | 1 | GB7G11 | Based on observation and interview the facility dietary department failed to maintain the mixer in a sanitary manner and failed to store dietary equipment and food in a sanitary manner. The findings included: Observation on December 6, 2010, at 10:23 a.m., with the Dietary Manager, of the dish machine in operation revealed fourteen dish racks in contact with the floor in front of the dish machine. Further observation revealed a measuring cup and the cup handle in contact with the rice stored in a bin. Continued observation revealed a mixer covered in plastic. Continued observation revealed the mixer under side area of the beater arm and the mixer bowl guard had multiple brown and white dried splatters and a white powdery substance present. Interview, with the Dietary Manager, on December 6, 2010 at 10:23 a.m., confirmed the following: 1.) There were fourteen dish racks in contact with the floor in front of the dish machine in operation. 2.) There was a measuring cup and the cup handle in contact with the rice stored in a bin. 3.) The mixer under side area of the beater arm and the mixer bowl guard had multiple brown and white dried splatters and a white powdery substance present. Continued interview revealed the plastic cover over the mixer meant the mixer was clean and ready for use. Further interview confirmed the above items were not maintained in a sanitary manner. | 2014-12-01 |
| 13491 | 13491 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2010-12-08 | 441 | D | 0 | 1 | GB7G11 | Based on observation and interview the facility failed to store nebulizer tubing and mask, and a tracheostomy humidifier mask in a sanitary condition for one resident (#3) of twenty-six residents records reviewed. The findings included: Observation on December 6, 2010 at 12:27 p.m., revealed a nebulizer on one bed side table and a tracheostomy humidifier machine on a bed side table, on the opposite side of the bed, of resident #3. Further observation revealed the nebulizer tubing and mask were in contact with the bed side table and the uncovered nebulizer. Continued observation revealed the tracheostomy humidifier mask was in contact with the bed side table. Interview, with Certified Nurse Aide #4 and Licensed Practical Nurse #3, on December 6, 2010, at 12:32 p.m., in the resident's room, confirmed the nebulizer tubing and mask were in contact with the uncovered nebulizer and the bed side table. Continued interview confirmed the tracheostomy humidifier mask was in contact with the bed side table. Continued interview confirmed the the nebulizer tubing and mask, and the tracheotomy humidifier mask were to be stored in a plastic bag after use. Interview with Registered Nurse (RN) #6, on December 6, 2010 at 12:35 p.m., in the resident's room, confirmed the nebulizer tubing and mask, and the tracheotomy humidifier mask were not stored properly after use. | 2014-12-01 |
| 13492 | 13492 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2010-12-08 | 281 | D | 0 | 1 | GB7G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to obtain a physician's order for the administration of oxygen for one resident (#1) of twenty-six residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of hospital physician orders dated November 17, 2010, revealed no orders for oxygen administration. Medcial record review of the physician's orders for December 2010 revealed no physician's order for oxygen administration. Observation on December 6, 2010, at 9:45 a.m., revealed the resident in bed with oxygen in use at 2.5 liters per minute (l/m). Observation on December 7, 2010, at 9:55 a.m, revealed the resident receiving oxygen at 3 (l/m). Interview with the Medical Director on December 8, 2010, at 6:30 p.m., in the Director of Nursing's office, confirmed the hospital orders did not reflect the use of the oxygen and confirmed no physician orders were given for the use of the oxygen since the resident's return to the nursing home on November 17, 2010. | 2014-12-01 |
| 13493 | 13493 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2010-12-08 | 323 | D | 0 | 1 | GB7G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility investigation, observation, and interview, the facility failed to ensure safety devices were in place for one resident (#3) of twenty-six residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no memory deficits, had difficulty making decisions in new situations, required extensive assistance with transfers, required limited assistance in locomotion on and off the unit, and had experienced a fall in the past 31-180 days. Medical record review of Fall Risk Assessments since December 17, 2009, revealed the resident was high risk for falls. Review of a facility investigation dated April 23, 2010, revealed the resident had slid out of the wheelchair and dycem had been applied to the wheelchair. Medical record review of the current care plan revealed a talking PSA (Pressure Sensitive Alarm) had been added to the resident's wheelchair and bed and dycem had been placed in the seat of the wheelchair. Observation on December 6, 2010, at 12:40 p.m., revealed the resident in a wheelchair without the personal safety alarm or the dycem in place. Observation on December 6, 2010, at 1:55 p.m., revealed the resident in bed without a personal safety alarm in place. Observation on December 7, 2010, at 9:05 a.m., with the Director of Nursing revealed the resident in bed without the personal safety alarm in place and no dycem or personal safety alarm on the wheelchair. Interview with the Director of Nursing on December 7, 2010 at 9:05 a.m., in the resident's room, confirmed the facility had failed to ensure the safety devices were in place to alert staff of unassisted transfers and sliding down in the wheelchair. | 2014-12-01 |
| 13664 | 13664 | LIFE CARE CENTER OF COLLEGEDALE | 445294 | PO BOX 658, 9210 APISON PIKE | COLLEGEDALE | TN | 37315 | 2011-07-07 | 157 | D | 1 | 0 | FO8N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to notify the family of a change in condition for one (#3) of fourteen residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a laboratory report dated October 21, 2009, revealed "...BUN (Basic Urea Nitrogen) 36 (normal limits 8 - 24)...Creatinine 60 (normal limits 6.0 -25.0)..." Medical record review of a laboratory report dated February 3, 2010, revealed "...BUN 39...Creatinine 43.1..." Medical record review of a nursing note dated February 4, 2010, at 8:00 a.m., revealed "3rd (third shift) nurse reported resident had many episodes of diarrhea. Given [MEDICATION NAME] (medication for diarrhea) on that shift. Resident still having diarrhea. Also weak and lethargic. Stool has foul smell with some mucus present..." Medical record review of a nursing note dated February 4, 2010, at 6:00 p.m., revealed "MD (Medical Doctor) N/O (new order) stat stool sample for [MEDICAL CONDITION] (Clorstridium Difficile)...obtained and sent to lab (laboratory)..." Medical record review of a nursing note dated February 4, 2010, at 8:00 p.m., revealed "Culture for [MEDICAL CONDITION] was negative. Results called to NP (Nurse Practitioner)..." Medical record review of a physician's orders [REDACTED]. Medical record review of a physician's orders [REDACTED]." Medical record review of a physician's orders [REDACTED]." Medical record review of a laboratory report dated February 9, 2010, revealed "...BUN 44...Creatinine 55.4..." Medical record review of the facility's documentation revealed the resident had fifteen bowel movements on February 4, 2010, eighteen on February 5, 2010, eight on February 6, 2010,, seven on February 7, 2010, one on February 8. 2010, and none on February 9, 2010. Medical record review revealed the resident did not have any diarrhea after February 9, 2010. Medical record revi… | 2014-11-01 |
| 1803 | 1803 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2018-07-18 | 755 | D | 0 | 1 | ZGG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of controlled drug records, observation and interview, the facility failed to ensure controlled medications were accurately recorded for 2 residents (#48 and #73) of 9 residents reviewed for [MEDICATION NAME] useage (anxiety medication) during medication storage review. The findings include: Review of facility policy Controlled Drugs, undated revealed .A 'controlled drugs proof of use sheet' is accurately maintained on all residents requiring controlled medications .appropriate storage, recording, and use of controlled drugs are maintained on all units .when controlled keys change hands during a shift, controlled drugs are recounted and both nurses sign the change of shift count record .if the count is incorrect, notify the supervisor and pharmacist .Note: The nurse remains on duty until the count is reconciled or the supervisor has given permission to leave . Observation, controlled drug record review, and interview with the Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) #2 on 7/18/18 at 8:15 AM, at the 100 hall medication cart, revealed Resident #48's controlled drug record documented the pharmacy dispensed 28 tablets of [MEDICATION NAME] 0.5 milligrams (mg) on 7/17/18 for Resident #48. Continued review revealed the facility documented 30 tablets had been received from the pharmacy. The count was off by 2 tablets. Review of Resident #73's controlled drug record revealed the pharmacy dispensed 60 tablets of [MEDICATION NAME] 0.5 mg on 6/19/18 for Resident #73. Continued review revealed the facility began the medication count at 30 tablets instead of 60 tablets. The count was off by 30 tablets. The ADON and LPN #2 confirmed Resident #48 and Resident #73's Controlled Drug Records for [MEDICATION NAME] count were incorrect. Interview with the ADON on 7/18/18 at 8:15 AM, at the 100 hall medication cart, confirmed the facility failed to ensure controlled medications were accurately … | 2020-09-01 |
| 1804 | 1804 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2018-07-18 | 761 | D | 0 | 1 | ZGG211 | Based on facility policy review, observation and interview, the facility failed to ensure medications remained under the direct observation of the person administering, during medication administration for the 21 residents in the secure unit. The findings include: Review of facility policy General Dose Preparation and Medication Administration, dated 5 2010, revealed .Facility staff should not leave medications or chemicals unattended . Observation of Licensed Practical Nurse (LPN) #1 on 7/16/18 at 4:10 PM, revealed LPN #1 removed the following medications: [REDACTED]. Further observation revealed LPN #1 dispensed medications from the packaging into the medication cup. Continued observation revealed LPN #1 left the medications unattended on top of the medication cart as she walked down the hall to open a closet door for a staff member. Continued observation revealed LPN #1 had her back to the medication cart as she walked down the hall. Further observation revealed Resident #15 and Resident #22 wandered near the unattended medications. Interview with LPN #1 on 7/16/18 at 4:15 PM, at the medication cart in the secure unit, confirmed LPN #1 walked away from the cart with medication in a cup unsecured while residents were wandering around the cart. Continued interview confirmed LPN #1 failed to follow facility policy. Interview with the Assistant Director of Nursing on 7/17/18 at 3:20 PM, in the Assistant Director of Nursing's office, confirmed the facility failed to ensure medications remained under the direct observation of the person administering during medication administration and failed to follow the facility policy. | 2020-09-01 |
| 1805 | 1805 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2018-07-18 | 812 | D | 0 | 1 | ZGG211 | Based on facility policy review, observation and interview, the facility failed to ensure resident food was labeled and failed to ensure staff beverages were not stored in 1 resident nourishment refrigerator of 2 nourishment refrigerators observed. The findings include: Review of the facility policy For Guests: Keeping Food Safe for the Residents in Ridgeview Terrace of Life Care undated, revealed .Storage of Food .b. Food requiring refrigerated storage must be placed in a container that is covered securely. It must contain a label that has the name of resident, what the item is, the date it was stored & (and) the 'use by date' .e. During rounds, any food found not to be stored properly will be discarded .9. When to Discard Food .c. If there is no date on the food item . Observation of the resident nourishment refrigerator on 7/17/18 at 2:47 PM, on the secure unit revealed a partially eaten hamburger in a paper bag. Further observation revealed the food was not labeled with a resident's name, date it was stored, or a use by date. Continued observation revealed an opened bottle of a soft drink which belonged to a staff member. Interview with Licensed Practical Nurse #3 on 7/17/18 at 2:47 PM, in the secure unit nurses' station confirmed the food was not labeled and confirmed the soft drink belonged to a staff member. Interview with the Director of Food and Nutrition on 7/17/18 at 2:48 PM, in the secure unit nurses' station confirmed resident food items are expected to be labeled with the resident's name and the date the food item was placed in the refrigerator. Continued interview confirmed staff food items or drinks were not to be stored in the resident nourishment refrigerator and the facility failed to follow facility policy. | 2020-09-01 |
| 4823 | 4823 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2016-07-27 | 157 | D | 0 | 1 | Q27811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review and interview, the facility failed to notify the resident's representative of a significant change in condition for 1 resident (#102) of 38 residents reviewed. The findings included: Review of the facility policy Changes in Resident's Condition or Status, revealed .Nursing services will be responsible for notifying the resident, his/her next of kin, or representative .when .There is a significant change in the resident's physical, mental, or emotional status . Medical record review revealed Resident #102 was admitted to the facility 1/14/15 with [DIAGNOSES REDACTED]. Medical record review of the Progress Notes dated 5/10/16 3:27 PM, revealed .congested with audible rhonchi required suctioning with O2 (oxygen) sat (saturation) of 82 (percent) on RA (room air) elevated temp (temperature) refused to eat placed on O2 at 3L (liters) sat up to 91 (percent) only after suctioning MD notified of condition . Medical record review of the Progress Notes dated 5/10/16 10:35 PM revealed .MD ordered [MEDICATION NAME] 875mg (milligrams) po (by mouth) BID (twice a day), [MEDICATION NAME] inhalation solution .q (every) 6 hours, and CXR (chest xray) . Medical record review of the Progress Notes dated 5/11/16 revealed .appx (approximately) 2 pm niece at facility upset because resident wasn't feeling well .obtained order to send to (hospital) . Interview with Licensed Practical Nurse (LPN) #2 on 7/27/16 at 9:40 AM, by telephone, confirmed the facility did not notify the family when new orders had been received for Resident #102 on 5/10/16. Interview with the Assistant Director of Nursing (ADON) on 7/27/16 at 2:30 PM, in the staff development office confirmed the family had not been notified of the change in Resident #102's condition. | 2019-07-01 |
| 4824 | 4824 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2016-07-27 | 315 | D | 0 | 1 | Q27811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review and interview, the facility failed to complete an urinary incontinence assessment for 1 resident (#10) of 3 residents reviewed for urinary incontinence, of 38 residents reviewed. The findings included: Review of the facility policy, Bowel (and) Bladder Training .Guidelines to Assessment . revealed .Quarterly: An Assessment for Bowel and Bladder Training is completed if the resident is incontinent. If there has been a change from the last quarter to this quarter, and the score is 0-14, proceed to completing the Urinary Incontinence Assessment. If no change has occurred, document why you will not be proceeding to the Urinary Incontinence Assessment . Medical record review revealed Resident #10 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident was frequently incontinent of urine. Medical record review of the Assessment for Bowel and Bladder Training dated 4/28/16 revealed, .(score) 12 .7-14 .Candidate for toileting, timed or scheduled voiding .If score is 0-14 .Quarterly .If score is changed from last quarter, complete Urinary Incontinence Assessement .If no change in score, document below why not proceeding to Urinary incontinence Assessment . Medical record review of the back of the Assessment for Bowel and Bladder Training dated 4/28/16 revealed no documentation related to the 4/28/16 assessment. Interview with the Assistant Director of Nursing (ADON) on 7/26/16 at 2:45 PM, at the nursing station confirmed the bladder assessment had not been completed on 4/28/16 to develop an individualized bladder retraining program. | 2019-07-01 |
| 4825 | 4825 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2016-07-27 | 329 | D | 0 | 1 | Q27811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain a laboratory level for [MEDICATION NAME] as ordered for 1 resident (#37) of 3 residents reviewed for behaviors, of 38 residents reviewed. The findings included: Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's note dated 4/16/16 revealed .continues to have a lot of yelling .no benefit from [MEDICATION NAME] (antipsychotic medication) and [MEDICATION NAME] (mood stabilizer) .going to discontinue both . continue to monitor . Medical record review of a physician's orders [REDACTED].D/C (discontinue) [MEDICATION NAME] .[MEDICATION NAME] level (laboratory level) . Medical record review revealed no laboratory report for the [MEDICATION NAME] level. Medical record review of Medication Administration Record [REDACTED]. Interview with the Administrator and the Director of Nursing, on 7/27/16 at 1:00 PM, in the Administrators office, confirmed the facility failed to obtain the [MEDICATION NAME] level for Resident #38 as ordered by the physician. | 2019-07-01 |
| 4826 | 4826 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2016-07-27 | 441 | D | 0 | 1 | Q27811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation and interview, the facility failed to ensure proper hand hygiene prior to medication administration for 1 resident, (#4) of 5 residents observed for medication administration. The findings included: Review of the facility policy, Eye Instillation revealed .Wash hands thoroughly before beginning the procedure .should both eyes require instillation, wash your hands before treating the second eye . Observation with Licensed Practical Nurse (LPN) #1 on 7/26/16 at 10:35 AM revealed LPN #1 gathered medications, entered Resident #4's room, raised the head of the bed, checked the Resident's armband, and applied gloves without washing the hands. LPN #1 then administered [MEDICATION NAME] eye drops to the Resident's eye. Interview with LPN #1 on 7/26/16 at 10:40 AM, in the hall, confirmed the hands were not washed prior to applying gloves and administering the eye drops to Resident #4. | 2019-07-01 |
| 6398 | 6398 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2015-07-29 | 241 | D | 0 | 1 | 9C4E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, medical record review, and interview, the facility failed to promote care for residents in a manner that maintains or enhances each resident's dignity and respect for 2 residents of 63 residents observed during dining in 2 of 3 dining rooms. The findings included: Review of facility policy, Meal Service, revised 10/2008 revealed, .Nursing Services will distribute food trays .in a timely manner .all residents at a table are served at the same time . Observation on 07/27/15 at 11:57 AM, in the main dining room revealed 1 resident at a table of 3 residents, of 34 residents waited for 20 minutes to be served while other residents at the table were eating. Interview with the Administrator on 7/27/15 at 4:00 PM, in the conference room confirmed the resident was not served in a timely manner. Medical record review revealed Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on 7/27/15 at 12:19 PM in A/B dining room revealed 4 residents seated at a table. Continued observation revealed 3 of the residents eating lunch and Resident #53 at the table with no meal. Observation on 7/27/15 at 12:26 PM of Resident #53 revealed no lunch meal tray at the table. Continued observation revealed Certified Nursing Assistant (CNA) #8 brought Resident #53's lunch at 12:36 PM. Interview with CNA #8 on 7/27/15 at 12:44 PM, in the A/B dining room confirmed Resident #53 did not receive a lunch tray in a timely manner. | 2018-08-01 |
| 6399 | 6399 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2015-07-29 | 441 | D | 0 | 1 | 9C4E11 | Based on facility policy review, observation, and interview, the facility failed to distribute and serve food under sanitary conditions for 29 residents of 34 residents observed in 1 of 3 dining rooms. The findings included: Review of facility policy, Meal Service, revised 10/2008 revealed, .Observe (standard) universal precautions .Wash hands before and after . Observation on 07/27/15 at 11:57 AM, in the main dining room revealed Certified Nursing Assistant (CNA) #1, CNA #2, Dietary Cook Aide #1, Dietary Cook Aide #2, and Licensed Practical Nurse (LPN) #1 preparing trays and cutting up food for 34 residents. Further observation revealed staff going from resident to resident without sanitizing hands for 29 residents of the 34 residents. Interview with LPN #1 on 7/27/15 at 12:40 PM, in the main dining room confirmed the facility failed to maintain hand sanitation while serving meals. | 2018-08-01 |
| 6400 | 6400 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2015-07-29 | 464 | D | 0 | 1 | 9C4E11 | Based on observation and interview, the facility failed to provide adequate space for comfortable dining in 1 (secure unit) of 3 dining areas. The findings included: Observation of dining on 7/27/15 at 12:00 PM revealed 17 cognitively impaired residents seated in the dining area of the secure unit at two tables. Table #1 had space for 10 residents to sit comfortably while dining and table #2 could comfortably sit 5 residents. The secure unit had capability of housing 20 residents. Continued observation of table #1 revealed 10 residents seated for dining and table #2 revealed 6 residents seated for dining including one resident who was seated at the corner of the table. One resident was seated in a chair along the wall. Table #2 also had activity supplies on one end of the table. Interview with Certified Nurse Aide (CNA) #7 on 7/27/15 at 12:40 PM, in the dining area confirmed if all the residents were in the dining area, the space would not be big enough. Further interview confirmed area is crowded and a bedside table is used when needed for the chair along the wall. Continued interview confirmed We use a bedside table sometimes for the chair along the wall but we try not to use it because it is an obstacle for the residents. | 2018-08-01 |
| 8107 | 8107 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2014-04-09 | 246 | D | 0 | 1 | 1WV011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure access to a call light for one resident (#19) of forty residents reviewed. The findings included: Resident #19 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident required extensive assistance for bed mobility, transfers, and locomotion. Medical record review of the resident's care plan, last updated on March 10, 2014, revealed, .resident has ADL (activities of daily living) Self-Care Deficit ext (extensive) to total for all adl's . Observation on April 8, 2014, at 9:04 a.m., revealed the resident was sitting in a wheelchair on the right side of the bed and the resident's call light was lying on the resident's pillow on the left side of the bed. Continued observation revealed a fall mat was lying on the floor between the resident and the right side of the bed. Interview with the resident on April 8, 2014, at 9:06 a.m., revealed, .I want to go to bed .my call light is over there and I can't reach it . Interview on April 8, 2014, at 9:07 a.m., with Registered Nurse #2, in the resident's room, confirmed the resident could not reach the call light and .it should be within reach . | 2017-08-01 |
| 8108 | 8108 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2014-04-09 | 441 | D | 0 | 1 | 1WV011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to follow infection control techniques during glucose monitoring for two residents (#137 and #36) on one of four hallways observed. The findings included: Review of facility policy, Cleaning and Disinfection of the Glucometer, dated March 2010, revealed .the following procedure is to be completed in the resident's room after a glucometer (device to check blood sugars) check before leaving the room .follow the steps below after you have taken the glucometer reading .pick up the glucometer .disinfect it .(named brand) wipe or an equivalent product that kills hepatitis B and blood-borne pathogens .Observation of a glucose monitoring (blood sugar check) with Registered Nurse (RN) #1 on April 8, 2014, at 3:44 p.m., on the 300 hall, revealed RN #1 obtained the glucometer from the top of the medication cart, entered resident #137's room, stuck the resident's finger with a lancet (a pricking needle), obtained a drop of blood on a glucose strip, inserted the glucose strip in the glucometer, and after obtaining the blood sugar result, exited resident #137's room without cleaning the glucometer. Continued observation revealed RN #1 then entered resident #36's room with the glucometer, stuck the resident's finger with a lancet, obtained a drop on a glucose strip, inserted the glucose strip in the glucometer, and after obtaining the blood sugar result, exited resident #36's room, without cleaning the glucometer, and placed it on the medication cart. Interview with RN #1 on April 8, 2014, at 3:50 p.m., outside room [ROOM NUMBER], confirmed, .did not clean it and I am supposed to . Further interview confirmed RN #1 did not follow infection control techniques. | 2017-08-01 |
| 10328 | 10328 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2013-03-13 | 157 | D | 0 | 1 | AET811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation, observation, and interview, the facility failed to notify the physician of a decline in ambulation and transfer for one resident (#123) of forty-one residents reviewed. The findings included: Resident #123 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident required supervision for transfers, walking in room, corridor, locomotion on and off unit, and no mobile devices. Medical record review of Nursing Rehabilitation/Restorative Care Daily Flow Record dated February 22, 2013, revealed .PROM (Passive range of motion) BLE (bilateral lower extremities) and ambulation 4 times a week. Res (resident) averaged 24-68 ft (feet) this week . Medical record review of a Rehabilitation Services Multidisciplinary Screening Tool dated February 27, 2013, revealed .Patient had fall on 2/28/13 with no injuries noted .Patient varies from using manual WC (wheelchair) to amb (ambulating) with RW (rolling walker) to amb without assistive device in living environment dependent on the day, time & (and) how (resident) feels .Bed Mobility sup (supervise) for safety .transfers sit to stand sup for safety .balance & falls .Fair .appropriate in manual wc, able to propel .Not appropriate for skilled therapy at this time . Medical record review of a Nurse Progress Note dated March 1, 2013, at 8:33 a.m., revealed .Resident noted lying in floor on Rt (right) side between .wheelchair and dining room chair .peers noted resident leaning forward with piece of toast in floor to residents Rt. side .no injuries noted .Neuro (neurological) checks completed and WNL (with in normal limits) . Review of a facility investigation dated March 1, 2013, revealed .resident was leaning forward to pick up a piece of toast on floor and fell .Transfer to regular straight back chair for meals .Therapy intervention beginning… | 2016-07-01 |
| 10329 | 10329 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2013-03-13 | 319 | D | 0 | 1 | AET811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow Psychiatric recommendations for one resident (#136) of forty-one residents reviewed. The findings included: Resident #136 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a fourteen day Minimum Data Set (MDS) dated [DATE], revealed severely impaired cognitively, delusions, verbal behaviors 1-3 days per week, and wanders daily. Medical record review of a Care Plan dated November 19, 2012, and updated February 7, 2013, revealed .resident is at risk for physical or mental decline .disease processes will be treated as needed through next review .provide psychosocial/mental health interventions as needed . Medical record review of the Physician's Recapitulation Order's dated March 2013 revealed .12/20/12: Psych (psychiatric) to eval (evaluation) and tx (treat) as indicated . Medical record review of a Psychiatric Note dated December 20, 2012, revealed .Psychotherapy to eval and tx .Is PCP (primary care physician) in agreement with recommendations .yes . Medical record review revealed no documentation of a completed Psychotherapy evaluation. Observation on March 12, 2013, at 2:30 p.m., on the 400 hall, revealed the resident ambulating per self attempting to exit the secure unit. Interview with the Social Worker on March 13, 2013, at 7:15 a.m., in the Social Worker's Office, confirmed the resident had not been referred to the Psychologist for Psychotherapy in December. | 2016-07-01 |
| 10330 | 10330 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2013-03-13 | 371 | F | 0 | 1 | AET811 | Based on observation and interview, the facility failed to maintain proper sanitation for food preparation equipment and hand washing in the dietary department. The findings included: Observation and interview on March 11, 2013, from 9:30 a.m. to 10:15 a.m., in the dietary department, with the Dietary Manager, revealed the following: 1. a condensation pipe located over the top of uncovered fresh vegetables in the walk-in cooler, had a steady drip 2. a microwave had dried food particles on the sides, top, and bottom, the glass turn table had a brown ring, and on the inside top and bottom of the microwave heavy rust 3. a fire extinguisher pipe over the stove top had heavy loose dust particles with food cooking uncovered Interview with the Dietary Manager on March 11, 2013, from 9:30 a.m. to 10:15 a.m., in the dietary department confirmed the following: 1. the condensation pipe in the walk-in cooler had been dripping over the top of fresh vegetables 2. the microwave had dried food particles and had visible rust in the microwave on the top and bottom 3. the fire extinguisher pipe had visible heavy dust particles and food had been cooking under the pipe Observation and interview on March 12, 2013, from 11:43 a.m. to 11:55 a.m., in the Dietary Department with the Dietary Manager, revealed the Dietary Manager washed the hands, opened the lid of a thirty gallon gray trash can, and disposed of the paper towels. Interview with the Dietary Manager on March 12, 2013, from 11:43 a.m. to 12:10 p.m., in the Dietary Department, confirmed the trash can lid had been dirty and no step trash can had been available at the hand washing sink. | 2016-07-01 |
| 10331 | 10331 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2013-03-13 | 431 | D | 0 | 1 | AET811 | Based on review of facility policy, observation, and interview, the facility failed to ensure a proper disposal method had been followed for a controlled substance. The findings included: Review of the facility policy Medication Destruction no date revealed .Controlled substances are washed down the toilet or sink . Observation and interview on March 12, 2013, at 11:03 a.m., in the 100 hall, revealed Licensed Practical Nurse #1 disposed of a Hydrocodone 5/500 milligram in the sharps container on the medication cart. Interview with the Director of Nursing on March 12, 2013, at 1:30 p.m., in the staff development office, confirmed the facility failed to follow the proper disposal method for a controlled substance. | 2016-07-01 |
| 10332 | 10332 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2013-03-13 | 441 | E | 0 | 1 | AET811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview, the facility failed to follow their policy on Clostridium Difficile (C. difficile) for resident (#146) of fourty-one resident's reviewed. The findings included: Review of facility policy, Clostridium Difficile, last revised on July 18, 2011, revealed .gloves are worn to enter the room of a resident who has diarrhea caused by [DIAGNOSES REDACTED]icile (a gastrointestional irritation and bacteria) .a gown is needed .if substantial contact with the resident or environmental surfaces is anticipated . Resident #146 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. difficile, and Diabetes. Observation on March 11, 2013, at 12:07 p.m., in the isolation room, revealed the Certified Occupational Therapy Assistant returned the resident #146 to the room, assisted the resident back to bed, and exited the room without wearing gloves or washing hands. Observation on March 11, 2013, at 12:30 p.m., in the 300 hallway, revealed Certified Nursing Assistant #1 entered the isolation room, exited, and continued down the hall without cleaning hands prior to contact with other resident's. Observation on March 11, 2013, at 12:42 p.m., in the isolation room, revealed laundry personnel entered the isolation room, touched several items including furniture without wearing personal protective equipment. Interview with the Assistant Director of Nursing (ADON) on March 11, 2013, at 1:03 p.m., in the ADON's office, confirmed gloves must be worn at all times by the staff while in the isolation room and gowns must be worn if contact with the resident or environmental surfaces is anticipated. | 2016-07-01 |
| 12523 | 12523 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2011-06-29 | 505 | D | 0 | 1 | TWMH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to promptly notify the physician of laboratory results for one resident (#9) of twenty-eight residents reviewed. The findings included: Resident #9 was admitted to the facility December 30, 2009, with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated October 16, 2010, at 8 a.m., revealed "...FNP (Family Nurse Practitioner) at facility, assessed Rt (right) heel at nurse's request..." Medical record review of a physician's telephone order dated October 16, 2010, revealed "...wound c/s (culture and sensitivity) of R (right) heel; fax results to office..." Medical record review of the laboratory results dated [DATE], revealed the culture sample was collected on October 17, 2010. Medical record review of a nurse's note dated October 25, 2010, at 9:05 a.m., revealed "...faxed preliminary wound culture from R heel, results to...(physician's name) office at 7 a.m. this morning." Medical record review of a nurse's note dated October 28, 2010, at 3 p.m., revealed "...C&S refaxed to MD (medical doctor) per MD request..." Medical record review of a physician's telephone order dated October 28, 2010, revealed "...Bactrim DS 1 PT (per tube) BID (twice daily) x 7 days..." Interview with the DON (Director of Nursing) June 29, 2011, at 10:45 a.m., in the conference room, confirmed the physician was not notified promptly of the wound culture results for this resident resulting in a delay of care. | 2015-08-01 |
| 12524 | 12524 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2011-06-29 | 333 | D | 0 | 1 | TWMH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility investigation, and interview, the facility failed to ensure that residents were free from medication errors for one resident (#19) of twenty-eight residents reviewed. The findings included: Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed a nurse's note dated December 24, 2010, at 7:15 a.m., by LPN #1 revealed "...Res (resident) received wrong meds (medications), MD notified, new orders rec (received) et (and) noted - to monitor BPs (blood pressures) et APs (apical pulse rate/heart rate) hourly et call MD back with drop in BP/AP..." Continued medical record review revealed an order was also received to hold administration of resident #19's prescribed blood pressure medications ([MEDICATION NAME] 0.2mg (milligram)/hr (hour) patch and [MEDICATION NAME] 20mg tablet) for the morning of December 24, 2010. Review of facility investigation dated December 27, 2010, further revealed that a medication error had occurred on December 24, 2010, at 6:15 a.m., during the morning medication pass, when LPN #1 administered three pills prescribed for another resident to resident #19. Continued medical record review revealed two of the three medications administered were blood pressure medications (Lisinorpil 40mg and [MEDICATION NAME] 20mg). Interview with the DON (Director of Nursing) on June 29, 2011 at 9:10 a.m., at the 100/200 hall nursing station confirmed resident #19 received the wrong medications as described above. | 2015-08-01 |
| 13408 | 13408 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2011-09-26 | 323 | G | 1 | 0 | L75811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility provided documentation (investigation), and interview, the facility failed to ensure a safety device was turned on to alert staff of unassisted transfers for one resident (#1) of five residents reviewed. The facility's failure to ensure the bed alarm was turned on for resident #1 resulted in a fall and a left orbital floor fracture (facial bone under the left eye) and soft tissue injury to the left orbit (facial tissue near the left eye) (Actual Harm). The findings included: Resident #1 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Nursing Assessments dated [DATE] and 16, 2011, revealed the resident had short-term memory loss. Medical record review of a Fall Risk Evaluation dated [DATE], revealed a resident who scores ten or higher is at risk (of falls); the resident scored six. Medical record review of nurse's notes dated [DATE], 10, 17, 18, and 23, 2011, revealed the resident was "confused." Medical record review of two Rehabilitation Multidisciplinary Screening Tools, both dated [DATE], revealed the following: (Screening #1) "...Comments: Nursing staff came to rehab gym this morning to get wc (wheelchair) for patient secondary to instability with gait and poor endurance-putting (resident) at increased risk for falls when staff was trying to assist (resident) to dining room...Cognition: poor memory, poor historian...Transfers: sit to stand with CGA (care giver assist); bed to WC with CGA...Balance and Falls:...high risk for falls...Other: visual deficits...(Screening #2) "...Comments: Pt (patient) presents with poor endurance, decreased strength in UE's (upper extremities) and LE's (lower extremities), decreased balance and coordination, poor safety awareness with transfers, decreased ability to perform ADLs (Activities of Daily Living) and transfers safely...Dressing/Grooming/Bathing/Hygiene: needs assistance...Transfers: needs assist… | 2015-01-01 |
| 14142 | 14142 | RIDGEVIEW TERRACE OF LIFE CARE | 445300 | PO BOX 26 COFFEY LANE | RUTLEDGE | TN | 37861 | 2010-07-08 | 514 | D | F7WP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain complete fluid intake/output documentations for two (#4 and #23) of twenty five residents reviewed. The findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Continued record review revealed a physician's admission order for "[MEDICATION NAME] 1.2 by peg (feeding) tube per pump 115 ml (milliliters) 9:00 p.m. and stop at 5:00 a.m., flush with 30 ml water before and after feeding and flush peg tube with 300 ml each shift." Review of comprehensive care plan dated May 7, 2010 revealed interventions for Nutrition/Hydration included "Intake and Output". Review of the facility Intake and Output Record for fluids for the month of May 2010, reveal documentation for the 300 ml water flush incomplete on 17 of 30 days and the "24 hour totals" incomplete on 28 of 30 days. Interview with the Director of Nursing on July 8, 2010, at 10:15 a.m., at the nurse's station confirmed the fluid intakes were incomplete. Resident # 23 was admitted to the facility February 19, 2010 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]." Review of the facility Minimun data set dated [DATE], under special treatments/procedures and programs indicate Intake/Output to be monitored. Review of the facility Intake and Output Record for fluid from February 19, 2010, to discharge date on March 1, 2010, revealed the 100 ml water flushes, the 250 ml bolus feedings and the "24 hour totals" incomplete for 17 of 20 days. Interview with the Director of Nursing on July 8, 2010, at 10:15 a.m., at the nurse's station, confirmed the fluid intakes were incomplete. | 2014-04-01 | ||
| 1554 | 1554 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2018-04-26 | 609 | D | 1 | 0 | F2N711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility investigation and interview the facility failed to report timely one abuse investagation of 5 abuse investigations reviewed. Findings Include: Review of a facility investigation dated 4/8/18 revealed on the evening of 4/7/18 Resident #11 reported to Certified Nurse Aide (CNA) #1 he was missing a large sum of money from his room. Continued review revealed CNA #1 approached Nurse #1 around 9:00 PM on 4/7/18 and told her she had something to tell her but as Nurse #1 was busy passing medications, CNT #1 told Nurse #1 she would tell her later. Further review revealed around midnight on 4/8/18 CNT #1 reported to Nurse #1 Resident #11 had told her he was missing money. Continued review revealed Nurse #1 did not report the allegation of abuse to the facility administration. Nurse #1 reported the allegation to the oncoming nurse supervisor around 7:00 AM on 4/8/18. Resident # 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS) revealed a score of 15/15 indicative of the resident was cognitively intact. Resident #11 required minimal assistance with activities of daily living (ADL) and used a wheelchair to self propel for mobility. Resident #11 has left sided paralysis and continent of bowel and bladder. Interview with Resident #11 on 4/25/18 at 10:57 AM in his room revealed Resident #11 stated he had gone to the bank on 3/28/18 and withdrew the $1200.00 and showed surveyor the receipt. Continued interview revealed Resident #11 stated he kept his wallet in his pants pocket when he was out of his room and at night when he sleeps he locks his wallet in his drawer in the cabinet next to his bed and he keeps the key in his pillow case. Continued interview revealed on the morning of 4/2/18 when he awoke around 6:00 AM, he noticed the key to the drawer was almost hanging out of the pillow case and his money was gone. When asked why he waited until 4/7/18 to rep… | 2020-09-01 |
| 1555 | 1555 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2017-07-12 | 371 | F | 0 | 1 | 4CWP11 | Based on observations, review of the 2013 Food Code, review of facility policy, observation and interview, the facility failed to follow appropriate glove use, handwashing, and personal hygiene including proper nail care to prepare and serve food in accordance with professional standards for food service in 1 of 1 main kitchen and 1 of 3 dining rooms. This had the potential to affect 124 residents. The findings include: Review of the 2013 Food Code from the U.S Department of Health and Human Services, pages 46, 50 and 74, Food employees shall use the following cleaning procedure in order stated to clean their hands and exposed portions of their arms .1. Rinse under clean, running warm water, 2. Apply an amount of cleaning compound; 3. Rub vigorously for at least 10 to 15 seconds .Food employees shall keep their fingernails trimmed, filed .Unless wearing intact gloves in good repair, a food employee may not wear fingernail polish or artificial fingernails when working with exposed food .Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry .If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled. Review of facility policy Dietary Policies: Personal Hygiene dated 8/24/16, revealed Nails- keep nails short and clean without chipped or colored nail polish .Follow hand washing procedures: vigorously rub together all surfaces of hands, fingertips and lower arms for 20 seconds .Gloves should not be worn when performing the following tasks: Holding scoops, tongs or other food service equipment utensils used to plate food. Observation of the main dining room tray line service on 7/12/17 at 7:04 AM revealed Baker #1 serving meals. She had a pair of gloves on. She proceeded to touch tray tickets and serving utensils. She grabbed the pancakes, bacon, toast and fried eggs with her gloved hands. No glove change or hand washing was observed. She rep… | 2020-09-01 |
| 1556 | 1556 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2017-07-12 | 431 | E | 0 | 1 | 4CWP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation and interview, the facility failed to ensure all medications available were in date for 2 of 3 medication rooms. The findings revealed: Review of the facility policy, LTC Facility's Pharmacy Services and Procedures Manual, revised [DATE] revealed .4 .Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier . Observation with Licensed Practical Nurse (LPN) #2 on [DATE], at 11:50 AM in the North Medication Room, observing refrigerated medications, revealed 1 bottle of Prilosec with approximately ,[DATE] of liquid medication remaining in the bottle, with an expiration date of [DATE]. Continued review revealed 1 unopened bottle of Milk of Magnesia 473 milliliters (ml) with an expiration date of ,[DATE]. Observation with Registerd Nurse #1 on [DATE], at 12:00 PM, in the West Medication Room of refrigerated medications revealed 6 bags of Intravenous (IV) Clindamycin (antibiotic) 300 milligram (mg)/50 ml with expiration date [DATE] and 3 bags of IV Ceftriaxone (antibiotic) 1 gram (gm)/50 ml with an expiration date [DATE]. Interview with the Director of Clinical Services on [DATE], at 12:42 PM, in the conference room confirmed the facility had failed to dispose of all outdated medications. | 2020-09-01 |
| 1557 | 1557 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2017-07-12 | 441 | D | 0 | 1 | 4CWP11 | Based on facility policy review, observation and interview, the facility failed to ensure staff disinfected their hands between glove change during wound care for 1 of 2 staff observed. The findings included: Review of the facility policy, Gloves, revised 5/5/06 revealed .8. Handwashing is necessary when gloves are removed . Observation of Licensed Practical Nurse (LPN) #1 on 7/12/17 at 11:00 AM, during a wound dressing change in a Resident #86's room revealed LPN #1 removed the old dressing with gloved hands; donned new gloves; cleaned the wound: removed the gloves: donned new gloves; measured and staged the wound; removed the gloves and donned new gloves. Interview with the Director of Clinical Services on 7/12/17 at 12:45 AM in the conference room confirmed the staff failed to follow facility policy and failed to ensure staff disinfected their hands between glove changes. | 2020-09-01 |
| 1558 | 1558 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2019-08-14 | 710 | D | 0 | 1 | NLRY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to ensure the physician order [REDACTED].#63) of 5 residents reviewed. The findings include: Facility policy review, Clinical Psychoactive Drug Reduction Policy, dated 3/1/16, revealed .Residents who use antipsychotic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. (The facility) will not utilize PRN psychoactive drugs for more than 14 days; if the resident requires the medication for more 14 days, the Medical Director must write an order for [REDACTED].>Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].[MEDICATION NAME] ([MEDICATION NAME]) Solution 2 mg (milligram)/ml (milliliter) (anti-anxiety medication) give 0.5 ml sublingually every 8 hours as needed for anxiety . Further review revealed no stop date, clinical explanation or rationale for continued use. Telephone interview with the Pharmacy Consultant on 8/13/19 at 8:52 AM confirmed there was no stop for the PRN (anxiety) medication for Resident #63. Further interview revealed, he stated I usually do not make recommendations to the Physician regarding PRN anti-anxiety medications for Hospice residents because they need them. Telephone interview with the Medical Director on 8/14/19 at 5:37 PM confirmed PRN [MEDICAL CONDITION] medications required a 14 day stop date or a rationale for continued use. Further interview revealed, he stated I am not sure how the 14 day stop date was missed on the order. | 2020-09-01 |
| 1559 | 1559 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2019-08-14 | 756 | D | 0 | 1 | NLRY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the Pharmacy Consultant failed to make recommendations for a stop date related to a PRN (as needed) [MEDICAL CONDITION] medication for 1 (#63) of 5 residents reviewed. The findings include: Facility policy review Clinical Psychoactive Drug Reduction Policy, dated 3/1/16, revealed .Residents who use antipsychotic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. (The facility) will not utilize PRN psychoactive drugs for more than 14 days; if the resident requires the medication for more 14 days, the Medical Director must write an order for [REDACTED].>Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].[MEDICATION NAME] ([MEDICATION NAME]) Solution 2 mg (milligram)/ml (milliliter) (anti-anxiety medication) give 0.5 ml sublingually every 8 hours as needed for anxiety . Further review revealed no stop date, clinical explanation or rationale for continued use. Telephone interview with the Pharmacy Consultant on 8/13/19 at 8:52 AM confirmed there was no stop date for the PRN ( anti-anxiety) medication for Resident #63. Further interview confirmed I usually do not make recommendations to the Physician regarding PRN anti-anxiety medications for Hospice residents because they need them. | 2020-09-01 |
| 1560 | 1560 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2019-08-14 | 758 | D | 0 | 1 | NLRY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to have a stop date for 1 (#63) of 5 residents reviewed after 14 days for PRN (as needed) [MEDICAL CONDITION] medication. The findings include: Facility policy review Clinical Psychoactive Drug Reduction Policy, dated 3/1/16, revealed .Residents who use antipsychotic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. (The facility) will not utilize PRN psychoactive drugs for more than 14 days; if the resident requires the medication for more 14 days, the Medical Director must write an order for [REDACTED].>Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].[MEDICATION NAME] ([MEDICATION NAME]) Solution 2 mg (milligram)/ml (milliliter) (anti-anxiety medication) give 0.5 ml sublingually every 8 hours as needed for anxiety . Further review revealed no stop date, clinical explanation or rationale for continued use. Telephone interview with the Pharmacy Consultant on 8/13/19 at 8:52 AM confirmed there is no stop date for the PRN ( anti-anxiety) medication for Resident #63. Further interview revealed I usually do not make recommendations to the Physician regarding PRN anti-anxiety medications for Hospice residents because they need them. Telephone interview with the Medical Director on 8/14/19 at 5:37 PM confirmed PRN [MEDICAL CONDITION] medications required a 14 day stop date or a rationale for continued use. Further interview he stated I am not sure how the 14 day stop date was missed on the order. Interview with the Director of Clinical Services on 8/14/19 at 5:45 PM in the training room, when asked to review Resident #63's physician order [REDACTED]. | 2020-09-01 |
| 1561 | 1561 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2019-08-14 | 759 | D | 0 | 1 | NLRY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to ensure 1 (#423) of 8 residents received medication as prescribed by the physician during medication pass observation. The findings include: Facility policy review, General Dose Preparation and Medication Administration, dated 01/01/13, revealed .facility staff should verify that the medication name and dose are correct .verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time .confirm that the MAR (medication administration record) reflects the most recent medication order . Medical record review of Resident #423's physician order [REDACTED].[MEDICATION NAME] Sodium Tablet 200 MCG (microgram), Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION], UNSPECIFIED, start date 8/9/19 . Medical record review of Resident #423's physician order [REDACTED].[MEDICATION NAME] Sodium Tablet 175 MCG Give 1 tablet by mouth in the morning for [MEDICAL CONDITION], Discontinued, end date, 8/8/19 . Medical record review of Resident #423's Medication Administration Audit Report dated 8/6/19 through 8/13/19 revealed .[MEDICATION NAME] Sodium Tablet 200 MCG given to Resident #423 on 8/13/19 at 6:11AM . Observation of Licensed Practical Nurse (LPN) #1 on 8/13/19 at 8:45 AM in Resident #423's room revealed LPN #1 administered [MEDICATION NAME] Sodium 175 MCG to Resident #423. Interview with LPN #1 on 8/13/19 at 4:57 PM at the West Hall nurse's station revealed the order for Resident #423's [MEDICATION NAME] was changed to be given daily at 6AM. Continued interview confirmed LPN #1 gave Resident #423 [MEDICATION NAME] 175 MCG at the 9 AM medication pass. Interview with the Director of Nusing (DON), the Assistant Director of Nursing (ADON) and the Assistant Director of Clinical Services on 8/14/19 at 5:00 PM in the DON's office revealed, when … | 2020-09-01 |
| 1562 | 1562 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2019-08-14 | 761 | D | 0 | 1 | NLRY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation and interview, the facility failed to remove an expired medication from the medication cart and failed to store a medication in the refrigerator per manufacturer's guidelines. The Findings include: Facility policy review, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, revised 7/23/19, revealed, .Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts and refrigerators . Observation of the medication cart for the West A Hall with Licensed Practical Nurse (LPN) #2 on 8/13/19 at 4:15 PM revealed one bottle of Acidophilus ([MEDICATION NAME]) opened on 8/5/19 and not refrigerated, label clearly states refrigerate after opening. Interview with LPN#2 on 8/13/19 at 4:15 PM on the West A Hall revealed when asked to review the label on the bottle of the [MEDICATION NAME] LPN #2 confirmed the medication was to be stored in the refrigerator. Observation of the medication cart on West Hall B with LPN #1 on 8/13/19 at 4:35 PM revealed 1 bottle of Aspirin 325 milligrams (mg) expired 7/2019. Interview with LPN#1 on 8/13/19 at 4:35 PM at the West Hall B medication cart confirmed the bottle of Aspirin 325mg was expired. Interview with LPN#1 on 8/14/19 at 2:02 PM at the West Hall nurse station revealed when asked what the process is for expired medications on the cart, LPN #1 replied expired medications were not to be on the carts, the nurses go through the carts periodically and discard of any expired medications. Interview with the Director of Nursing (DON) on 8/14/19 at 4:50 PM in the DON's office revealed when asked if she would expect to see any expired medications or medications which must be refrigerated on the medication cart, the DON replied I would expect to see manufacturers guidelines followed on medications and expired medications must be removed from medication carts . | 2020-09-01 |
| 1563 | 1563 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2019-08-14 | 812 | D | 0 | 1 | NLRY11 | **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 serve food in a sanitary manner for 1 (#221) of 42 residents during the noon meal on 8/12/19. The findings include: Facility policy review, Food Handling Guidelines, dated 5/13/15, revealed .Do not touch food directly with your hands . Medical record review revealed Resident #221 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #221's Baseline Care Plan dated 8/7/19 revealed the resident required meal set up by staff. Observation on 8/12/19 at 11:48 AM in the main dining room during the noon meal service revealed Certified Nursing Assistant (CNA) #1 setting up Resident #221's meal tray. Continued observation revealed CNA #1 opened the resident's crackers and touched them with her bare hand and placed them in the resident's plate. Interview with CNA #1 on 8/12/19 at 11:49 AM in the main dining room when asked the procedure for handling resident's food she stated Normally I wear gloves, I didn't think about it; I touched (Resident #221's) crackers with my bare hands. Interview with the Director of Nursing on 8/12/19 at 4:48 PM in her office when asked the procedure for handling resident's food she stated the policy states bare hands were not to be touching the food; I expect staff not to touch the resident's food with their bare hands. | 2020-09-01 |
| 1564 | 1564 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2019-08-14 | 880 | D | 0 | 1 | NLRY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to dispose of a used intravenous (IV) medication bag and tubing after administration for 1 (#171) of 1 resident reviewed receiving intravenous therapy. The findings include: Medical record review revealed Resident #171 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #171's baseline care plan dated 8/9/19 revealed the resident received intravenous antibiotics. Medical record review of Resident #171's Order Summary Report dated 8/10/19 revealed .[MEDICATION NAME] (HCL) (an antibiotic used to treat bacterial infections) 2 grams (gm)/100 milliliter (ml) use 1 vial intravenously every 12 hours for UTI . Observation on 8/12/19 at 10:02 AM in Resident #171's room revealed the resident lying in bed. Continued observation revealed an IV pump at the resident's bedside with an empty bag labeled [MEDICATION NAME] 2 gm to run over 1 hour at 100 ml hour hanging on the pump. Continued observation revealed the bag was initialed and dated 8/10/19. Observation and interview on 8/12/19 at 10:07 AM in Resident #171's room with Licensed Practical Nurse #1 present when asked procedure for disposal of used intravenous medications and supplies she stated usually we would take it down after it was administered and throw it away, they (bag and tubing) needed to have been thrown away. Interview with the Director of Clinical Services on 8/12/19 at 4:04 PM outside of the conference room confirmed when IV medication is completed the bag and tubing needed to be thrown away. Continued interview she stated there's no specific policy for this; it's just standard of practice. Interview with the Director of Nursing on 8/12/19 at 4:48 PM in her office when asked the procedure for disposing of completed IV medications and tubing she stated Ideally when it's finished you would remove the bag and tubing and throw it away. | 2020-09-01 |
| 1565 | 1565 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2018-11-07 | 609 | D | 1 | 0 | LV7111 | **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 a suspected allegation of abuse within the 2-hour time frame as required to the State Agency. Continued review revealed nursing staff failed to report a suspected allegation of abuse immediately to the Administrator according to facility policy for 1 resident of 3 sampled residents (Resident #1) reviewed for abuse. The findings include: Review of the facility policy, Abuse & Neglect of Residents and Misappropriation of Resident's Property revised 11/9/16 revealed .the incident .reported to the Department of Health within prescribed time frame (2 hours) .any alleged violation involving .neglect, abuse .must be reported immediately to the Administrator . Medical record review revealed Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicting no cognitive impairment. Total assistance of 2 staff was required for transfers, toileting, personal hygiene, and bathing. Continued review revealed Resident #2 was always incontinent of bowels and had an indwelling urinary catheter in place. Further review revealed the resident's pain level was frequently assessed, he was appropriately medicated for pain, and relief was received from the pain medication. Resident #2 received nutrition and hydration by way of a gastrostomy tube (GT) (a tube to provide liquid nutritional supplementation into the stomach). Review of the facility investigation revealed .on 10/23/18 at approximately 9:00 AM (Administrator) was notified .was an allegation .the State Incident reporting system was notified of the initial allegation on 10/23/18 . The time indicated in the Incident Reporting System (IRS) Identification was 1729; 5:29 PM in standard time. Telephone interview with Licensed Practical Nurse (… | 2020-09-01 |
| 5827 | 5827 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2015-11-10 | 223 | D | 1 | 0 | 09ZM11 | **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 ensure the safety of a resident immediately after an inappropriate incident for 1 (Resident #1) of 5 residents reviewed. The findings included: Review of the facility policy entitled Abuse & Neglect of Residents and Misappropriation of Residents' Property approved 2/20/13, revealed .Any alleged violations involving mistreatment, neglect, abuse, or misappropriation including injuries of unknown source, must be reported immediately to the Administrator . Continued review of the policy revealed the investigation includes: 1. Notification of the involved resident's legal guardian or responsible family member. 2. Facility investigation will include: a. Interviewing the resident victim. b. Interviewing the alleged perpetrator. c. Interviewing all persons with firsthand knowledge of alleged incident. d. Physical examination of resident victim for evidence of abuse or neglect. f. Photographing evidence where appropriate. g. Obtaining written statements from victim, witnesses, other persons with reported knowledge as appropriate. i. Collecting, reviewing, and retaining pertinent facility documentation which may have a bearing on a full and proper investigation. 3. Any employees/volunteer/ contractor alleged to be involved in suspected abuse, neglect, or misappropriation will be removed from direct care until completion of the investigation. 4. If the alleged violation is verified, appropriate corrective action will be taken. 5. Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. 6. Analysis of further staff training and/or monitoring needs related to residents' rights, resident care needs of the confused or behaviorally disturbed resident, etc . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED… | 2018-11-01 |
| 5828 | 5828 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2015-11-10 | 328 | D | 1 | 0 | 09ZM11 | **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 correctly transcribe a physicians order for the use of oxygen, failed to follow the facility policy for transcribing and reviewing physician orders [REDACTED].#4) of 5 residents reviewed. The findings included: Review of a facility policy titled, Transcription of Physician order [REDACTED].Guidelines have been established to ensure physician orders [REDACTED].The licensed nurse is responsible to clarify any physician order [REDACTED].or confusing prior to transmission to the pharmacy or transcription on the medication administration record .Information must not be added in to any order .The night shift charge nurse .completes a 24 hour chart check each night indicating that all orders for the preceding 24 hours period orders have been properly transcribed and executed .any issue or discrepancies shall be addressed at this time and communicated to ensure 100% of all physician orders [REDACTED]. If discrepancies are found they are to be corrected by the .nurses. This will serve as a triple check of all orders. Review of a facility policy titled, Oxygen Policy dated 2/20/13 revealed, .Oxygen will only be administered with a physician's orders [REDACTED]. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was seen in the Emergency Department on 9/2/15 with a [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired, had symptoms of inattention and altered level of consciousness that fluctuated for 1-3 days, needed extensive assistance from 2 people for activities of daily living, did not ambulate, used a wheel chair for mobility and had received oxygen therapy within the previous 14 days while in the facility. Medical record review of a Physician's Telephone Orders sheet dated… | 2018-11-01 |
| 6040 | 6040 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2015-08-19 | 281 | D | 0 | 1 | R8SI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow physician's orders for 1 resident (#151) of 33 residents reviewed. The findings included: Medical record review revealed Resident #151 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's Order dated 5/7/15 revealed .[MEDICATION NAME] Ointment (Antibiotic) apply to incision Left eye BID (twice a day) .Post-op (operative) incision . Medical record review of the Medication Administration Record [REDACTED]. Medical record review of a Physician's Order dated 8/19/15 revealed .clarification order: [MEDICATION NAME] ointment start date 4/30/15 stop 5/14/15 .post op . Observation on 8/18/15 at 7:45 AM revealed the resident in the bed being fed breakfast by a staff member. Interview with the Director of Nursing (DON), on 8/19/15 at 10:10 AM, in the conference room confirmed the [MEDICATION NAME] Ointment had not been administered as ordered by the Physician. | 2018-10-01 |
| 6041 | 6041 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2015-08-19 | 322 | D | 0 | 1 | R8SI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview, the facility failed to ensure medications administered per enteral tube (feeding tube) were given safely and accurately to 1 resident (#62) of 2 residents reviewed for enteral tube medication administration of 33 residents sampled. The findings included: Review of facility policy, Preparation For Medication Administration, no date revealed .Purpose .To safely and accurately administer oral medications through an enteral tube .verify tube placement .insert a small amount of air into the tube with syringe and listen to stomach with stethoscope .allow medication to flow down tube via gravity .do not push medications through the tube . Medical record review revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's Telephone Order dated 8/5/15 revealed .1 Gm (gram) NaCl (sodium chloride) tab (tablet) crushed in 120 ml (milliliter) H20 (water) per tube qd (every day) . Observation on 8/18/15 at 8:15 AM revealed Licensed Practical Nurse (LPN) #4 crushed a NaCl 1 Gm tablet. Continued observation revealed LPN #4 entered the resident's room placed the stethoscope on the resident's abdomen and auscultated bowel sounds. Further observation revealed LPN #4 placed the crushed medication in a medication cup with 10 ml of water, drew the medication and water up in the 60 ml syringe, and pushed the medication through the tube. Interview with LPN #4 on 8/18/15 at 8:35 AM, in the East Wing Hall confirmed the LPN failed to verify tube placement with a syringe prior to enteral tube medication administration and pushed the medication through a 60 ml syringe into the enteral tube. | 2018-10-01 |
| 6042 | 6042 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2015-08-19 | 332 | D | 0 | 1 | R8SI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to administer as ordered 1 medication per enteral tube for Resident (#62) and failed to administer 1 ordered medication to 1 resident (#11). The facility's failure to administer medications as ordered resulted in a medication error rate of 8 percent. The findings included: Medical record review revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's Telephone Order dated 8/5/15 revealed .1 Gm (gram) NaCl (sodium chloride) tab (tablet) crushed in 120 ml (milliliter) H20 (water) per tube qd (every day) . Observation on 8/18/15 at 8:15 AM revealed Licensed Practical Nurse (LPN) #4 crushed a NaCl 1 Gm tablet. Further observation revealed the LPN placed the crushed medication in a medication cup with 10 ml of water, drew the medication and water up in the 60 ml syringe, and pushed the medication through the tube. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated (MONTH) (YEAR) revealed .[MEDICATION NAME] Sod ([MEDICATION NAME]) 100 mg (milligram) tablets .take 2 tablets (200 mg) by mouth .for constipation . Observation on 8/18/15 at 7:43 AM, with LPN #4 confirmed the LPN administered [MEDICATION NAME] 1 tablet 100 mg (not 2 tablets) by mouth to Resident #11. Interview with LPN#4 on 8/18/15 at 8:55 AM, in the East Wing Hall confirmed LPN #4 failed to administer 200 mg of [MEDICATION NAME] to Resident #11 and failed to administer the NaCl per the enteral tube in 120 ml of H20 for resident #62. | 2018-10-01 |
| 6043 | 6043 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2015-08-19 | 425 | D | 0 | 1 | R8SI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure medications were provided by the pharmacy for 1 (#151) resident of 33 residents reviewed. The findings included: Medical record review revealed Resident #151 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 4/30/15 revealed .Surgical Repair of [DIAGNOSES REDACTED] (lower lid) of Left Eye . Medical record review of the Physician's Recapitulation Orders dated (MONTH) (YEAR) revealed .Vigamox (Antibiotic) .Instill 1 drop in left eye three times a day .[DIAGNOSES REDACTED] Repair . Medical record review of the Medication Administration Record [REDACTED].Vigamox .instill 1 drop in left eye three times a day . Continued review revealed the three doses on 5/16/15, 5/17/15, 5/18/15, and 5/19/15, were circled as not administered. Review of the reverse side of the MAR indicated [REDACTED].Vigamox ordered-pharmacy aware .5/17 9a/1p Vigamox on order-pharmacy aware .5/17 5p .Vigamox not available .5/18 9A .Vigamox not available .5/19 5p .Vigamox not available . Observation on 8/18/15 at 7:45 AM revealed the resident in the bed being fed breakfast by a staff member. Continued observation revealed the resident was clean shaven. Interview with the Director of Clinical Services, on 8/19/15 at 11:50 AM, in the lobby confirmed 12 doses of Vigamox were not available from the pharmacy. | 2018-10-01 |
| 6044 | 6044 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2015-08-19 | 431 | D | 0 | 1 | R8SI11 | Based on review of facility policy, review of facility documentation, review of manufacturer's recommendations, observation, and interview, the facility failed to sign out the controlled substance at the time of administration in 1 of 5 Controlled Substance Records observed and failed to ensure medications were stored at the proper temperature in 1 of 3 medication refrigerators reviewed. The findings included: Review of facility policy, Preparation For Medication Administration, no date revealed .Controlled Medications .When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record .dated and time of administration .amount administered .signature of the nurse administering the dose completed after the medication is actually administered . Observation with Licensed Practical Nurse (LPN) #5 on 8/18/15 at 2:07 PM, on the West Wing B-Hall revealed the LPN signing the accountability record multiple times. Interview with LPN #5 on 8/18/15 at 2:10 PM, on the West Wing B-Hall confirmed the LPN had failed to sign out the resident's controlled substances on the accountability record at the time of each administration. Interview with Director of Clinical Services on 8/18/15 at 3:05 PM, in the Training Room confirmed the LPN failed to administer the resident's controlled substances according to the Standard of Practice for Nurses. Review of facility policy, Medication Storage In The Facility, no date revealed .Medications are stored safely .following manufacturer's recommendations .medications requiring refrigeration or temperatures between 36 degrees and 46 degrees are kept in a refrigerator with a thermometer to allow temperature monitoring . Review of the facility's North Wing Medication Room Temperature Log dated (MONTH) (YEAR) revealed .Refrigerator Temperature (36-42) . Continued review revealed the refrigerator temperature had been recorded 17 of 18 days. Further review revealed the refrigerator temperatures had be… | 2018-10-01 |
| 6045 | 6045 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2015-08-19 | 441 | D | 0 | 1 | R8SI11 | Based on observation and interview, the facility failed to ensure sharps were disposed of safely in 1 of 3 opportunites observed. The findings included: Observation on 8/18/15 at 4:30 PM, in Resident #173's room revealed Licensed Practical Nurse (LPN) #3 performed an accucheck (fingerstick). Continued observation revealed LPN #3 picked up the lancet (sharp), test strip, and the alcohol pad in the gloved right hand. Further observation revealed LPN #3 removed the glove containing the items from the right hand and disposed of the glove with the items enclosed in the glove in the trash can in the resident's bathroom. Interview with LPN #3 on 8/18/15 at 4:48 PM, on the East A-Hall confirmed LPN #3 failed to dispose of the contaminated sharps in the sharp container. | 2018-10-01 |
| 8339 | 8339 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2014-04-23 | 246 | D | 0 | 1 | 6SMA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to provide reasonable accomodation of needs for one resident (#78) of twenty-four residents reviewed. The findings included: Resident #78 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident required extensive assistance of one person for eating, was usually understood, and usually understands others. Continued review revealed the resident's brief interview for mental status (BIMS) score as 12, indicating only moderate impairment. Observation in the resident's room, on April 22, 2014, at 7:54 a.m., revealed the resident sitting in the room, with a the breakfast tray present in the resident's room. Interview with the resident revealed the resident needed assistance with tray set up and had been waiting for fifteen minutes for help. Continued observation revealed the Corporate Nurse entered the resident's room at 8:01 a.m., (seven minutes later). Continued observation revealed the resident stated to the Corporate Nurse, I have been waiting for twenty minutes. Interview with the Corporate Nurse, on April 22, 2014, at 8:05 a.m., outside the resident's room confirmed the tray had been sitting at least ten minutes. Continued interview confirmed the resident could not reach the breakfast tray and needed assistance preparing the food to eat. Interview with Certified Nursing Assistant (CNA) #1, on the C hall, on April 23, 2014, at 11:02 a.m., revealed CNA #1 placed the breakfast tray in the room, but did not know how long the food had been sitting in the room, unavailable to the resident. Interview on April 23, 2014, at 11:12 a.m., with the Corporate Nurse, in the Corporate Nurse's office, confirmed the facility had failed to ensure the resident could begin eating when the breakfast tray was placed in the resident's room. | 2017-07-01 |
| 8340 | 8340 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2014-04-23 | 282 | D | 0 | 1 | 6SMA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to implement the care plan for one resident (#41) of twenty-four residents reviewed. The findings included: Resident #41 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident scored nine out of fifteen on the Brief Interview for Mental Status assessment, indicating moderate cognitive impairment. Continued review revealed the resident required extensive assistance of one for transfers and toileting, was frequently incontinent of urine, and was on a toileting program. Review of the Care Plan dated February 3, 2014, revealed, Scheduled Toileting: Assist resident to BR (bathroom) at 6a, 9a, 11a, 1p, 3p, 6p, HS (bedtime) and PRN (as needed). May assist 1 hr (hour) before/after scheduled times and as needed . Review of the Restorative Nurse's Note dated February 26, 2014, revealed, .resident continues on scheduled toileting program . Review of the scheduled toileting documentation revealed the following: 1) April 18, 2014 - The resident was toileted three of the six scheduled times for toileting between 6:00 a.m., and 6:00 p.m.; 2) April 19, 2014 - The resident was toileted five of the six scheduled times for toileting between 6:00 a.m., and 6:00 p.m.; 3) April 20, 2014 - The resident was toileted three of the six scheduled times for toileting between 6:00 a.m., and 6:00 p.m.; and 4) April 21, 2014 - The resident was toileted three of the six scheduled times for toileting between 6:00 a.m., and 6:00 p.m. Observation of resident #41 on April 22, 2014, at 4:30 p.m., in the restorative dining room on the East Wing, revealed the resident was seated in a wheelchair and appeared to be wearing an adult brief. Interview with the Licensed Practical Nurse/Restorative Nurse on April 23, 2014, at 9:40 a.m., at the East Wing nurse's station confirmed the facility had… | 2017-07-01 |
| 8341 | 8341 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2014-04-23 | 514 | D | 0 | 1 | 6SMA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure a complete and accurate medical record for catheter care for one resident (#129) of four resident's reviewed with indwelling catheters. The findings included: Resident #129 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set (MDS) dated [DATE], revealed the resident was admitted with the indwelling urinary catheter. Medical record review of the Care Plan dated February 14, 2014, and updated March 7, 2014, revealed the care plan reflected the resident was at risk for complications related to [MEDICAL CONDITION] and the chronic indwelling catheter. Continued review of the care plan revealed interventions to address the risk for complications included, .Observe for signs and symptoms of [MEDICAL CONDITION] and catheter care every shift . Review of the March and April 2014, Medication Administration Record [REDACTED]. Interview with the East Wing Unit Manager on April 23, 2014, at 10:24 a.m., at the East Wing Nurse's Station confirmed the facility had failed to maintain a complete and accurate medical record for catheter care for resident #129. | 2017-07-01 |
| 10291 | 10291 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2013-06-12 | 253 | D | 0 | 1 | JQZU11 | Based on observation and interview the facility failed to properly maintain equipment for one resident (#44) of thirty-one residents reviewed. The findings included: Observation on June 3, 2013, at 3:00 p.m., in the resident's room, revealed the resident lying in bed asleep. Further observation revealed the upper quarter size side rails were padded and in the raised position. Continued observation revealed the vinyl padding on the top of the right side rail was torn. Continued observations on June 4, 2013, at 7:30 a.m., and June 5, 2013, at 8:00 a.m., revealed the right upper quarter side rail padding had not been replaced. Observation and interview with Licensed Practical Nurse (LPN) #3 on June 5, 2013, at 8:00 a.m., in the resident's room, confirmed the side rail padding was torn. Interview with the Assistant Director of Nursing (ADON) on June 5, 2013, at 11:30 a.m., in the ADON's office, confirmed the replacement padding is readily available and should be replaced when torn. | 2016-07-01 |
| 10292 | 10292 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2013-06-12 | 441 | D | 0 | 1 | JQZU11 | Based on observation and interview the facility failed to maintain a sanitary environment for a shower room and a linen storage area to prevent possible contamination. The findings included: Observation during the initial tour on June 3, 2013, at 11:00 a.m., revealed in the West shower room had two medium size brown debris areas on the floor. Interview with Licensed Practical Nurse, (LPN #4) on June 3, 2013, at 11:05 a.m., in the West shower room, confirmed the areas of brown debris and confirmed the areas were to have been cleaned. Observation during the interview revealed the LPN #4 cleaned the areas and asked house-keeping to disinfect the shower room. Observation on June 3, 2013, at 11:05 a.m. revealed clean linen on the shelves of the West hall linen closet stored with an isolation door caddy equipped with isolation supplies, a milk crate, booties and a moveable covered linen cart that is taken into the hallway to deliver clean linen to the resident rooms. Interview with Licensed Practical Nurse (LPN) #4, on June 3, 2013, at 11:05 a.m. at the West hall linen closet, confirmed the clean linen in the storage closet was not covered and exposed to the other supplies stored in the closet. Observation on June 4, 2013, at 11:05 a.m. revealed the linen in the storage closet was uncovered and the isolation caddy, milk crate, booties and the covered moveable linen cart remained in the closet. | 2016-07-01 |
| 12251 | 12251 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2011-08-24 | 323 | D | 0 | 1 | MVJE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of facility documentation and interview, the facility failed to thoroughly investigate to determine if safety alarms were functional to prevent falls and failed to implement new interventions to prevent further falls for one resident (#8); failed to thoroughly investigate to determine if safety alarms were functional to prevent falls for one resident (#11) with multiple falls of twenty-five residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS (Minimum Data Set) dated April 25, 2011, revealed the resident had long and short term memory problems, moderately impaired decision making, was dependent for transfers and ambulation, and had experienced two falls since the last assessment. Medical record review of a nursing note dated March 14, 2011 at 2:45 p.m., revealed, Resident on alert charting D/T (due to) fall without injury. Medical record review of the facility's Post Fall Assessment and review of the facility's documentation revealed the resident had a fall from the wheelchair on March 14, 2011, and the resident was to have a sensor pad in place. Continued review revealed the facility had failed to determine if the sensor pad alarm had sounded at the time of the fall. Medical record review of the Interdisciplinary Careplan for Falls updated April 16, 2011, revealed the resident was to have a sensor pad alarm to the wheelchair and the bed. Medical record review of a nursing note dated May 3, 2011, at 8.36 p.m., revealed, Alerted by family member that resident was on the floor. Resident was laying on.(left) side (with) w/chair (wheelchair) touching back.Assessed for injury & (and) none noted.w/chair alarm sounded upon fall. Medical record review of a Change in Condition and Care Plan Update dated May 3, 2011, revealed the resident had an abrasion to the left elbow with a dry dressing applied a… | 2015-09-01 |
| 12252 | 12252 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2011-08-24 | 441 | D | 0 | 1 | MVJE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of facility policy, and interview, the facility failed to follow hand hygiene and infection control practices for one resident (#3) of twenty- five residents reviewed. The findings included: Resident (#3) was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical Record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was dependant on staff for ADL (activities of daily living) and incontinent of bowel. Observation on August 23, 2011, at 8:20 a.m., in the resident's room, revealed CNT #1 (Certified Nursing Technician) was performing daily personal care for the resident. Observation revealed CNT #1 cleaned stool from the resident, rinsed the buttocks area and changed gloves. Further observation revealed the resident had additional stool and CNT #1 cleaned the area with soap and water; wet an additional wash cloth; removed a bandage from the rectal area (with stool on the bandage); placed the bandage in the trash can and applied clean bed linens without washing the hands or changing gloves. Continued observation revealed CNT # 1 turned the resident, applied lotion to the resident's skin, and placed a clean gown on the resident without washing the hands or changing gloves. Interview with CNT #1, on August 23, 2011, at 8:35 a.m., in the hallway outside of the resident's room, confirmed the CNT failed to wash the hands or change gloves after removing stool from the rectal area and applying clean linens and lotion. Review of the facility policy Handwashing/Hand Hygiene, not dated and no policy number, revealed, .All persons shall follow our established handwashing/hand hygiene procedures to prevent the spread of infection.before moving from a contaminated body site to a clean body site during resident care.after handling used dressings.the use of gloves does not replace handwashing/hand hygiene. Interview with the Regional Compliance Nurse, on August 2… | 2015-09-01 |
| 13404 | 13404 | TENNESSEE VETERANS HOME | 445270 | PO BOX 10299 | MURFREESBORO | TN | 37129 | 2011-09-02 | 279 | D | 1 | 0 | GXEW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to update or revise the Care Plan to reflect the current level of care for four (#3, #6, #10, #12) of twelve residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Comprehensive Care Plan dated January 7, 2010, revealed "Potential for serious injury r/t (related to) falls...Assist with transfers. See ADL (Activities of Daily Living) Care Plan..." Continued medical record review revealed "Self-care deficit...Extensive assist x (times) 2 with transfers..." Review of the Nurse Aid's Information Sheet (Ceritfied Nursing Technician (CNT) Care Plan) dated August 26, 2009, revealed "...Transfer: 1 assist or 2 assist..." Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was alert and oriented; sometimes made repetitive statements; required maximum assistance with transfers, bathing, and dressing; was continent of bowel and bladder; required set-up for meals. Medical record review of Nursing Notes dated March 6, 2010, at 2:30 p.m., revealed resident #3 slid from the bed after being transferred by one CNT. Continued medical record review revealed the resident received a laceration to the knee and a leg fracture which resulted in an amputation. Interview with CNT #2 on September 1, 2011, at 2:20 p.m., in the conference room, revealed the CNT had transferred the resident alone on many occasions as had other CNTs. Continued interview revealed the resident used a walker and walked with a steady gait to the bathroom. Further interview revealed the resident used the walker for transfers to and from bed and chair but used a motorized wheelchair for transportation. Continued interview revealed the CNT was aware the CNT Care Plan stated to use 1 or 2 assist with transfers. Further interview revealed two CNTs transferred the resident when "...was tired or went to sl… | 2015-01-01 |
| 3054 | 3054 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2018-02-27 | 602 | D | 1 | 0 | MQRX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility's investigation, and interviews the facility failed to prevent misappropriation of property for 1 resident (#1) of 3 residents reviewed for misappropriation of property. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set ((MDS) dated [DATE] for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. Review of the facility policy, Abuse and Neglect of Residents and Misappropriation of Residents' Property, undated, revealed .TSVH (Tennessee State Veterans Home) takes a firm stand on the issues of mistreatment, neglect, or abuse of residents and the misappropriation of resident's property .Residents must not be subjected to abuse by anyone including, but not limited to: facility staff . Review of the facility policy, Abuse, Neglect, and Misappropriation Prevention Policy, undated, revealed .Every precaution will be taken to prevent mistreatment, neglect, and /or abuse of a resident or misappropriation of their property. Residents must not be subjected to abuse, neglect, or misappropriation by anyone .Misappropriation of residents property means the deliberate misplacement, exploitation, or wrongful, temporarily or permanent use of a resident's belongs or money without the resident's consent . Review of the facility investigation revealed on 2/7/18 at approximately 3:00 PM, the Social Service Director (SSD) informed the Administrator that Resident #1 had reported his credit card missing. Further review revealed when the Administrator and SSD went to the resident's room, his wife was present and shared a copy of the Resident's (MONTH) credit card statement. One traceable charge was a utility bill payment. Continue review revealed a report was filed with the (county) Sheriff'… | 2020-09-01 |
| 3055 | 3055 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2017-03-07 | 372 | C | 0 | 1 | ENX011 | Based on observation and interview, the facility failed to dispose of garbage and refuse in a sanitary manner for 3 of 3 dumpsters observed. The findings included: Observation with the Assistant Dietary Manager on 3/5/17 at 9:30 AM, outside at the dumpster area, revealed: a). six blue disposable gloves. b). dried debris on the ground along the base of the middle dumpster c). multiple cigarette butts d). empty condiment packages, an empty potato chip bag, small pieces of paper, and a card board food package. All items were on the ground behind the dumpsters. Interview with the Assistant Dietary Manager on 3/5/17 at 9:35 AM, outside at the dumpster area confirmed the facility failed to dispose of garbage and refuse in a sanitary manner Interview with the Director of Clinical Services on 3/6/17 at 11:19 AM, in the conference room confirmed the dumpster area had not been maintained in a sanitary manner. | 2020-09-01 |
| 3056 | 3056 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2019-04-24 | 657 | C | 0 | 1 | OQ0X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to provide documentation of Certified Nurse Aide (CNA) participation in the Care Plan process for 20 residents (#7, #8, #18, #24, #31, #45, #48, #50, #55, #69, #83, #95, #104, #108, #110, #111, #112, #115, #118, and #121) of 37 residents reviewed. The findings include: Review of the facility policy Clinical Comprehensive Care Plans Policy, dated 3/1/16 revealed .utilize information gathered .to develop, review and revise the Resident's Comprehensive Plan of Care .the Care Planning/Interdisciplinary Team .develops and maintains a comprehensive plan of care .that identifies the Resident's unique problems/weaknesses, strengths, preferences, goals and interventions .include, but not limited to .Nursing Assistants . Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] for [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 10/31/18 and 1/9/19 revealed no documentation of CNA participation for Resident #7. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 3/6/19 revealed no documentation of CNA participation for Resident #8. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 4/24/19 revealed no documentation of CNA participation for Resident #18. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan Meeting dated 11/8/18 and 2/11/19 revealed no documentation of CNA participation for Resident #24. Medical record review revealed Resident #31 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan meeting on 1/22/19 revealed no … | 2020-09-01 |
| 3057 | 3057 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2019-04-24 | 689 | D | 0 | 1 | OQ0X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, medical record review, observations, and interview the facility failed to complete an accurate falls risk assessment for 1 resident (#103) of 6 residents reviewed for accidents of 37 sampled residents. The findings include: Medical record review revealed Resident #103 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact, was continent of bowel and bladder, required limited assistance of 1 for mobility, tranfers, dressing and toileting and sustained a fall with injury. Medical record review of the falls risk assessments revealed the following: 4/18/18 - Falls risk score of 12 indicated the resident was a high risk for falls; 8/30/18 - Falls risk score of 18 indicated the resident was a high risk of falls; 12/7/18 - Falls risk score of 14 indicated the resident was a high risk for falls; 1/23/19 - Falls risk score of 6 indicated the resident was not at risk for falls; 3/18/19 - Falls risk score of 4 indicated the resident was not at risk for falls; Medical record review of facility documentation dated 1/23/19, revealed Resident #103 was observed on floor in shower in his bathroom with a laceration to the left side of his head. Continued review revealed the resident complained of left side rib pain, and the resident was sent to the hospital for evaluation. Interview with Licensed Practical Nurse (LPN) #2 on 4/24/19 at 4:34 PM, at the 200 nurse's station, revealed the nurse was responsible to complete a falls investigation and falls risk assessment after a fall. Continued interview confirmed LPN #2 had failed to include the fall on the 1/23/19 falls risk assessment. Interview with the Director of Nursing (DON) on 4/24/19 at 4:51 PM, in the DON's office confirmed the falls risk assessment dated [DATE] for Resident #103 was… | 2020-09-01 |
| 5151 | 5151 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2016-03-23 | 282 | D | 0 | 1 | 6TT311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to follow the care plan for 1 resident (#23) out of 4 residents reviewed for accidents of 32 sampled residents. The findings included: Review of the facility policy, Resident Lift Policy undated revealed .The Charge Nurse or Therapy staff representative will determine which lift is suitable for use. It is optimal for 2 staff members to be present during the use of resident lifts . Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE], revealed Resident #23 had a Brief Interview of Mental Status (BIMS) of 5 (indicating the resident was severely cognitively impaired). Continued review revealed the resident required extensive assistance of 2 persons for physical transfers. Medical record review of the Care Plan dated 1/27/14, revealed Resident #23 was care planned for being at risk for falls. Continued review revealed the resident required the assistance of 2 staff for Actvities of Daily Living (ADL's) and transfers. Review of the facility investigation dated 4/10/15 revealed a Certified Nurse Assistant used a sit to stand lift to transfer resident #23 into bed without assistance on 4/8/15. Interview with the Director of Nursing (DON) on 3/23/16 at 10:18 AM, in the DON Office, confirmed the resident was transferred on 4/8/15 by one person. Further interview confirmed Resident #23 required a 2 person assist with transfers and the facility failed to follow the care plan for Resident #23. | 2019-05-01 |
| 5152 | 5152 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2016-03-23 | 323 | D | 0 | 1 | 6TT311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to ensure adequate supervision was provided during transfer for 1 resident (#23) of 4 residents reviewed for accidents of 32 sampled residents. The findings included: Review of the facility policy, Resident Lift Policy undated revealed .The Charge Nurse or Therapy staff representative will determine which lift is suitable for use. It is optimal for 2 staff members to be present during the use of resident lifts . Medical record review revealed resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE], revealed Resident #23 had a Brief Interview of Mental Status (BIMS) of 5 (indicating resident was severely cognitively impaired). Continued review revealed the resident was an extensive assist and required 2 person physical assistance with transfers. Medical record review of the Care Plan dated 1/27/14, revealed Resident #23 was care planned for being at risk for falls. Continued review revealed the resident required the assistance of 2 staff for Actvities of Daily Living (ADL's) and transfers. Review of the facility investigation dated 4/10/15 revealed a Certified Nurse Assistant used a sit to stand lift to transfer resident #23 into bed without assistance on 4/8/15. Interview with the Director of Nursing (DON) on 3/23/16 at 10:18 AM, in the DON Office, confirmed the resident was transferred on 4/8/15 by one person. Further interview confirmed resident #23 required a 2 person assist with transfers. | 2019-05-01 |
| 5153 | 5153 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2016-03-23 | 371 | F | 0 | 1 | 6TT311 | Based on review of facility policy, facility temperature logs, observation, and interview, the facility failed to maintain proper temperatures of refrigeration equipment in 1 of 3 refrigerated units, maintain regulatory temperatures for 26 thickened milks, to remove a scoop from a stored food container, and to date and label opened resident food for 1 of 2 nourishment room refrigerators and for 1 of 1 kitchen reviewed that could have affected 119 residents. The findings included: Review of the facility policy, Dietary Policies, dated 5/13/15 revealed .the refrigerator .must be 41 degrees or less .temperatures of refrigeration equipment shall be reviewed and recorded at least twice daily .keep scoops out of the stored food containers .cover, label and date container . Review of the Daily Refrigerator Temperature Log, for the milk box for (MONTH) (YEAR), revealed .acceptable range: 32 degrees to 41 degrees . Further review revealed on 3/21/16 a recorded temperature of '42' for day shift and no recorded temperature for night shift. Continued review revealed the recorded temperature on 3/22/16 as '45' and not in use. Observation on 3/21/16 at 9:15 AM with Certified Dietary Manager (CDM) #1 at the milk box refrigerator in the kitchen revealed an internal temperature of 42 degrees Fahrenheit (F). Further review revealed the refrigerator contained thickened milks, house supplements, and juices. Observation with CDM #1 of the bottom shelf of the metal prep table on 3/21/16 at 9:40 AM, in the kitchen revealed a closed plastic container with 3 and 3/4 quarts of powdered milk. Continued observation revealed a saucer in the powdered milk. Observation of the plating of the lunch service on 3/21/16 at 11:25 AM, with the CDM #1 during the plating of the lunch service revealed a large plastic bucket filled with 16 thickened 2% (percent) white milks and 10 thickened chocolate milks in covered cups and covered with ice. Further observation revealed the temperature of the thickened 2% white milk at 45.2 degrees F. Continued observa… | 2019-05-01 |
| 5154 | 5154 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2016-03-23 | 441 | D | 0 | 1 | 6TT311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to ensure proper hand hygiene during a dressing change for 1 resident (#108) of 1 resident observed for dressing changes. The findings included: Review of the facility's policy, Handwashing/Hand Hygiene, revealed If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for all the following situations .3e. Before handling clean or soiled dressings, gauze pads, etc . Resident (#108) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician order [REDACTED].cleanse . with Normal Saline, Pat Dry. Apply Ca (calcium) Alginate top with foam Dressing . Observation of Resident #108 in the resident's room on 3/23/16 at 9:09 AM, revealed the Treatment Nurse/Registered Nurse (RN) provided a dressing change to Resident #108's right ankle. Continued observation revealed the Treatment Nurse removed the soiled dressing from the wound, and placed the dressing into a red biohazard bag. Continued observation revealed the Treatment Nurse/RN removed her gloves, disinfected her hands, cleansed the open wound with a moistened gauze pad, discarded the moistened gauze pad in the red biohazard bag, and proceeded to prepare the clean treatment and dressing for the wound without removing the gloves and disinfecting the hands. Continued observation revealed the Treatment Nurse/RN trimmed the alginate dressing by holding it in the center and cutting around the edges to custom fit the wound site. Continued observation revealed the Treatment Nurse/RN placed the alginate dressing over the open wound, and covered it with a padded self-adhesive dressing. Interview with the Treatment Nurse/RN on 3/23/16 at 10:10 AM, in the treatment nurse's office confirmed the Treatment Nurse/RN had failed to follow infection control procedures by not disinfecting her hands after clean… | 2019-05-01 |
| 9098 | 9098 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2014-01-23 | 371 | F | 0 | 1 | FZC111 | Based on observation, review of facility policy, and interview, the facility failed to ensure expired food items were disposed of in the walk-in refrigerator and failed to ensure pans used for cooking were stored clean and dry in the dietary department. The findings included: Observation of the walk-in refrigerator in the kitchen with the Dietary Manager on January 21, 2014, at 9:12 a.m., revealed one plastic container of twelve purchased hard boiled eggs with an expiration date of January 16, 2014. Review of the facility's policy titled Food Storage Chart, updated August 2013, revealed, .Commercially prepared food .recommended storage time when opened and stored in refrigeration .(is the) Manufacturers 'use by date' . Interview with the Dietary Manager on January 21, 2014, at 9:12 a.m., in the walk-in refrigerator, confirmed the hard boiled eggs were expired and available for use. Observation in the kitchen, on January 21, 2014, at 3:40 p.m., revealed a white oily substance on the inside of three of eleven full size steam table pans, stored as clean. Further observation revealed three of six muffin pans, stored as clean, had dried tan debris and carbon build up. Interview during the observation with the Dietary Manager on January 21, 2014, at 3:41 p.m., confirmed the muffin pans and steam table pans were soiled. | 2017-03-01 |
| 10918 | 10918 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2012-11-16 | 241 | C | 0 | 1 | C96E11 | Based on observation, interview, and review of facility policy, the facility failed to provide an environment that maintains or enhances each resident's dignity of thirty-two of seventy-five observed resident's during the dining observation. The findings included: Observation on November 13, 2012, at 11:15 a.m., in the Restorative Dining Room, revealed two Certified Nursing Assistants (CNAs) placing large cloth napkins on the resident's chest without asking the resident prior to placement. Further observation on November 13, 2012, at 12:10 p.m., in the Assisted Dining Room, revealed the Assistant Director of Nursing (ADON) and two CNAs placing large cloth napkins on the resident's chest without asking the resident prior to placement. Further observation on November 14, 2012, at 5:15 a.m., in the Restorative Dining Room, and 5:45 a.m., in the Assisted Dining Room, revealed CNAs placed large cloth napkins on the resident's chest without asking the resident prior to placement. Interview with the ADON on November 13, 2012, at 12:20 p.m., in the Assisted Dining Room, confirmed the staff placed large cloth napkins on each resident as a clothing protector without asking the residents if they wanted them. Interview with the Restorative Manager on November 14, 2012, at 6:00 a.m., in the Restorative Dining Room, confirmed the napkins were placed as clothing protectors without asking the residents if they wanted them. Review of facility policy, Dignity and Quality of Life Policy, revealed .using bibs or other clothing protectors instead of napkins except by Resident's choice . Observation on November 13, 2012, at 11:15 a.m., in the Restorative Dining Room, revealed the Speech Language Pathologist (SLP) was performing a swallowing study on one resident at a table of three. Prior to and during, observation the SLP failed to acknowledge the other residents at the table. Observation on November 13, 2012, at 12:25 p.m., in the Assisted Dining Room, revealed the Speech Language Pathologist (SLP) was performing a swallowing study … | 2016-04-01 |
| 14037 | 14037 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2009-02-19 | 280 | D | 1 | 0 | G2MS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to update the care plan to include appropriate repositioning techniques to prevent pain and potential injury to the shoulder for one resident recovering from shoulder surgery (#5) of five residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short or long-term memory problems, was independent with decision-making and required extensive assistance of two with bed mobility. Medical record review of the initial nursing assessment dated [DATE], revealed, " ... Incision line right shoulder has 23 staples, Incision (without) redness, a lot of bruising and [MEDICAL CONDITION] ..." Review of a Social Worker note dated November 2, 2008, revealed, " ... has use of both hands, although ... has to be careful due to ... recent right arm surgery / injury ..." Review of the care plan dated November 2, 2009, revealed the resident had discomfort related to the right shoulder surgery. Continued review of the care plan revealed, "... reposition frequently for comfort measures..." and revealed no interventions for safe and appropriate repositioning of the resident in bed. Review of documentation provided by the facility revealed on November 6, 2008, at 3:50 p.m., two Certified Nursing Assistants (CNAs) repositioned the resident in bed, with one CNA on the resident's left side and one on the right side, and the CNAs pulled the resident up in bed by the arms. The resident "cried out in pain." Continued review revealed the CNAs had no knowledge of the resident's recent surgery to the right shoulder prior to repositioning the resident in the bed and revealed the resident identified the pain level in the arm as '9' on a scale of 1 -10 (worst pain being 10) after being repositioned by the CNAs. Medical record review of a nurse's note da… | 2014-07-01 |
| 14038 | 14038 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2009-02-19 | 309 | D | 1 | 0 | G2MS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure staff appropriately repositioned to prevent pain and potential injury to the shoulder for one resident recovering from shoulder surgery (#5) of five residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short or long-term memory problems, was independent with decision-making and required extensive assistance of two with bed mobility. Medical record review of the initial nursing assessment dated [DATE], revealed, " ... Incision line right shoulder has 23 staples, Incision (without) redness, a lot of bruising and [MEDICAL CONDITION] ..." Review of a Social Worker note dated November 2, 2008, revealed, " ... has use of both hands, although ... has to be careful due to ... recent right arm surgery / injury ..." Review of documentation provided by the facility revealed on November 6, 2008, at 3:50 p.m., two Certified Nursing Assistants (CNAs) repositioned the resident in bed, with one CNA on the resident's left side and one on the right side, and the CNAs pulled the resident up in bed by the arms. The resident "cried out in pain." Continued review revealed the CNAs had no knowledge of the resident's recent surgery to the right shoulder prior to repositioning the resident in the bed and revealed the resident identified the pain level in the arm as '9' on a scale of 1 -10 (worst pain being 10) after being repositioned by the CNAs. Medical record review of a nurse's note dated November 7, 2008, at 7:15 p.m., revealed, "Received a call from (Physician Assistant) requesting this resident be sent to ... ER ... to have ... right shoulder evaluated for pain and possible trauma ..." Medical record review of a nurse's note dated November 7, 2008, at 8:45 a.m., revealed the resident was transported to the emergency r… | 2014-07-01 |
| 14296 | 14296 | SENATOR BEN ATCHLEY STATE VETERANS' HOME | 445484 | ONE VETERANS WAY | KNOXVILLE | TN | 37931 | 2010-06-03 | 323 | D | JRLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to ensure a safety device was in place for one resident (#5) of twenty-six residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was "...total dependence..." and required "...two + (plus) persons physical assist..." for transfers. Medical record review of a Plan of Care, dated November 2, 2009, revealed the resident was at risk for falls and was to use a "...Sit to Stand (used for transfers) lift for all transfers..." Medical record review of facility documentation dated, December 26, 2009, revealed, " ...CNA (Certified Nursing Assistant) who was assisting res (resident) with transfer was loosing safe grip. Res was safely lowered to floor to prevent fall..." Continued review of facility documentation revealed, "...Comments/Conclusion: Use lift for transfers, Two person transfers..." Interview with CNA #1 (on duty at the time of the fall) and the Director of Nursing, on June 2, 2010, at 9:40 a.m., in the Director of Nursing's office, confirmed the Sit to Stand lift was not in use on December 26, 2009, when the resident sustained [REDACTED]. | 2014-02-01 | ||
| 8568 | 8568 | SISKIN HOSPITAL SUBACUTE REHAB | 445420 | ONE SISKIN PLAZA | CHATTANOOGA | TN | 37403 | 2015-11-18 | 325 | D | 0 | 1 | 83BM11 | **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 follow facility policy for monitoring weight loss for 2 residents (#136 and #211), of 4 residents reviewed for weight loss, of 13 patients reviewed. The findings included: Review of the facility policy Weights revised 1/15 revealed, .Inpatients (residents) .will be weighed at time of admission. Patients (residents) are to be weighed weekly on Saturday or Sunday .it is the responsibility of CNA (Certified Nurse Aide) to check patient's most recent weight against last weight obtained and report significant weight loss or gain to patient's nurse. If discrepancy is 3 lbs (pounds), or greater the patient must be re-weighed . Medical record review revealed Resident #136 was admitted on [DATE] and discharged on [DATE] with a [DIAGNOSES REDACTED]. Medical record review of a care plan initiated 6/5/15 revealed, .alteration in nutrition (potential) evidenced by poor appetite .weight per md (doctor) orders. Weight as ordered weekly . Medical record review of a dietician note dated 6/8/15 revealed, .6/6 191# (pounds) standing (type of weight obtained) .5/30 189# standing + (plus) 2# or 1% (percent) BW (body weight) in Medical record review of a dietician note dated 6/15/15 revealed .6/14 wt (weight) in paragon (charting system) is 154#, standing. Did not use this for assessment wt d/t (due to) concern for accuracy. Will request reweigh . Medical record review revealed Resident #136's weights were not consistently obtained using the same type of scale and were recorded as: 6/4/15 by other (type of scale used)--191#; 6/6/15 by standing--192# (1 lb. weight gain in 2 days); 6/14/15 by standing--155# (37 lb. weight loss in 8 days); 6/21/15 by bariatric--151# (4 lb. weight loss in 7 days); 6/24/15 by standing--151#; 6/28/15 by standing--150# (1 lb. weight loss in 4 days). Medical record review of the nursing notes revealed no documentation the 37 lb. weig… | 2017-06-01 |
| 8569 | 8569 | SISKIN HOSPITAL SUBACUTE REHAB | 445420 | ONE SISKIN PLAZA | CHATTANOOGA | TN | 37403 | 2015-11-18 | 371 | F | 0 | 1 | 83BM11 | Based on facility policy, observation, and interview, the facility failed to store food in a sanitary manner and failed to maintain a sanitary kitchen. The findings included: Review of the facility policy, Food Safety Product Labeling and Dating Guide dated 7/29/14 revealed, .Receiving/Storing (Dry or Frozen)-Rotation System. Date cartons, cases, boxes, etc, with 'date received' . Review of facility policy, Nutrition Services Department (Dept) Cleaning Schedule, undated revealed, .Week Two Production-Convection Ovens-Convection Ovens cleaned and sanitized inside and out. Continued review revealed .Week Four-Production-Convection Ovens -Convection Ovens cleaned and sanitized inside and out . Observation of the walk-in freezer with the Food Service Director on 11/16/15 at 10:30 AM, in the kitchen, revealed the following items open and undated: 1. 1 bag of sweet potato fries 1/2 remaining 2. 3 bags of chicken tenders with 1/4- 1/2 remaining 3. 2 bags of tator tots with 1/4 remaining 4. 2 bags of onion rings with 1/2 remaining 5. 1 bag of chicken livers with 3/4 remaining 6. 1 bag of french fries with 1/3 remaining Interview with the Food Service Director on 11/16/15 at 10:35 AM, in the kitchen, confirmed the frozen food items were not sealed or undated. Observation with the Food Service Director on 11/17/15 at 1:35 PM, in the kitchen, revealed 3 of 4 ovens with a heavy build-up of brown and black debris on the bottom of the ovens and brown debris on the sides, doors, and glass windows of the ovens. Interview with the Food Service Director on 11/17/15 at 1:35 PM, in the kitchen, confirmed 3 of 4 ovens had a heavy build-up of brown and black debris. Interview with the Vice President of Quality on 11/17/15 at 2:06 PM, in the conference room, confirmed there were no cleaning logs or documentation of ovens being cleaned. | 2017-06-01 |
| 8570 | 8570 | SISKIN HOSPITAL SUBACUTE REHAB | 445420 | ONE SISKIN PLAZA | CHATTANOOGA | TN | 37403 | 2016-12-14 | 371 | F | 0 | 1 | MSD811 | Based on facility policy review, observation and interview, the facility failed to label and date food items in 1 of 1 walk in refrigerators, 1 of 1 walk in freezers, 1 of 1 nourishment refrigerators, securely cover food items in 1 of 1 walk in refrigerators and 1 of 1 walk in freezers, maintain a clean freezer in 1 of 2 freezers reviewed, and maintain a sanitary staff handwashing sink in 1 of 2 sinks reviewed, and failed to maintain a sanitary kitchen in 1 of 1 kitchen reviewed, affecting 27 of 27 residents. The findings included: Review of the facility policy, Sanitation and Infection control with a revised date of 3/2010 revealed, .All .pre-package open containers .are labeled, dated, and securely covered . Review of the facility policy, Food Safety Standards and Requirements revised 8/17/16 revealed .Handsinks must be clean, in good working condition and properly maintained . Review of the facility policy, Kitchen and Cafe Cleaning Frequencies dated 2011 revealed .POLICY .high standards of cleanliness and sanitation will be maintained .ICE MACHINE .Interior (bin) of the machine should be free of dirt, debris, and lime build up, smooth to the touch .All legs and shelving units are free of dirt and grease build up . Observation with the Dietary Manager (DM) on 12/13/16 at 11:48 AM, of the walk in refrigerator, revealed; A) A 5 pound bag approximately 1/3 full of white cheese opened to air undated, and available for resident consumption. B) A 2 pound plastic container of white cheese undated, unlabeled, and available for resident consumption. Observation with the DM on 12/12/16 at 11:50 AM of the walk in freezer, revealed; A) 22 frozen chicken patties undated, unlabeled, open to air, and available for resident consumption. B) Approximately 1/2 bag of frozen tater tots undated, unlabeled, open to air, and available for resident consumption. C) Approximately 1/3 bag of fries undated, unlabeled, open to air, and available for resident consumption. Observation with the DM on 12/13/16 at 9:30 AM of the kitchen staff … | 2017-06-01 |
| 9374 | 9374 | SISKIN HOSPITAL SUBACUTE REHAB | 445420 | ONE SISKIN PLAZA | CHATTANOOGA | TN | 37403 | 2013-08-28 | 164 | D | 0 | 1 | S9JN11 | Based on observation and interview the facility failed to ensure the privacy of health information for four of six patient records. The findings included: Observation of a medication cart on August 26, 2013, revealed the Registered Nurse (RN #1) was not at the medication cart from 11:12 a.m., to 11:22 a.m. Observation revealed a stack of nursing report sheets lying on the left side of the medication cart with the names of four residents on the report sheets visible. Observation continued and revealed the first report sheet contained private health information for one of the four residents. Interview at 11:23 a.m. on August 26, 2013, with RN #1, at the medication cart, verified there were four patients with names visible. Continued interview confirmed RN #1 had been away from the records and the patient's report sheet on the top of the stack contained private health information. | 2017-01-01 |
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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 );