CMS-Nursing-Home-Full-Deficiencies

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

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rowid	facility_name	facility_id	address	city	state	zip	inspection_date	deficiency_tag	scope_severity	complaint	standard	eventid	inspection_text	filedate
4850	ADAMSPLACE, LLC	445392	1927 MEMORIAL BOULEVARD	MURFREESBORO	TN	37129	2016-04-13	441	E	0	1	1NKU11	Based on observation and interview, the facility failed to store biohazard waste in a sanitary manner for one of two biohazard rooms observed. The findings included: Observation of wound care with the Wound Care Nurse on 4/13/16 at 9:27 AM, revealed the Wound Care Nurse completed a dressing change and placed visibly soiled items in a red biohazard bag. Continued observation revealed the Wound Nurse took the bag containing the biohazard items to a room labeled soiled utility, and then placed the biohazard items in a large wheeled plastic container. Further observation of the container revealed there was no red biohazard bag in the container; and there was a visibly soiled towel on the bottom of the container, multiple loose gloves, and a broke plastic fork. Interview with the Wound Care Nurse on 4/13/16 at 9:39 AM, confirmed the facility failed to follow infection control practice by not disposing of the biohazard items in an approved manner.	2019-07-01
8681	ADAMSPLACE, LLC	445392	1927 MEMORIAL BOULEVARD	MURFREESBORO	TN	37129	2013-11-20	278	D	0	1	GOZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to accurately identify pressure ulcers on the Admission Minimum Data Set (MDS) dated [DATE], for one resident (#91) of four residents reviewed for pressure ulcers. The findings included: Resident #91 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED]. Medical record review of the Weekly Wound Assessment Progress Note dated October 7, 2013, revealed .Lt (left) heel /c (with) 2 (two) sDTIs (Suspected Deep Tissue Injury). Areas are purple, intact blister. Tissue is mushy .Rt (right) heel /c DTI. Area is purple /c mushy, intact blister present .Stage One pressure ulcers present to bilateral ischial tuberosities . Medical record review of the MDS dated [DATE], revealed no pressure ulcers were documented. Interview with the MDS Coordinator, on November 20, 2013, at 1:35 p.m., in the MDS office, confirmed there no pressure ulcers were documented on the Admission MDS, and the MDS was inaccurate.	2017-05-01
8682	ADAMSPLACE, LLC	445392	1927 MEMORIAL BOULEVARD	MURFREESBORO	TN	37129	2013-11-20	281	D	0	1	GOZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, review of the meal intake record, facility policy review, and interview, the facility failed to weigh a resident weekly after admission and failed to reweigh the resident after a weight discrepancy for one resident (#224), of twenty residents reviewed. The findings included: Resident #224 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on November 19, 2013, at 12:30 p.m., and on November 20, 2013, at 8:30 a.m., revealed the resident in the resident's room self feeding the meals. Further observation revealed the resident consumed 75-100 percent of both meals observed. Medical record review of the Admission Minimum Data Set, dated dated dated [DATE], revealed the resident was moderately cognitively impaired and was independent with eating after set-up. Medical record review of the hospital data dated October 28, 2013, revealed the resident's initial weight was 64.5455 kilograms (142 pounds). Medical record review of the admission nursing assessment dated [DATE], revealed the resident's weight was 161 pounds, had bilateral lower extremity [MEDICAL CONDITION], and had complaints of difficulty/pain with swallowing. Medical record review of the Nursing Progress Notes dated November 2-10, 2013, revealed the resident had bilateral lower extremity [MEDICAL CONDITION], TED hose (compression device) worn, legs elevated on pillow, and/or bilateral heels off loaded. Medical record review of the Weight Record revealed the admission weight was 161 pounds and the usual body weight was 142 pounds at home. Further review of the Weight Record dated November 13, 2013, revealed the resident's weight was 140 pounds, a decrease of 21 pounds in fourteen days. Review of the meal intake record revealed the resident consumed 75-100 percent of every meal after November 11, 2013. Medical record review revealed the resident was ordered a speech therapy evaluation and treatment at admission and therapy remained ongoing with improvement. Review of an undated facility policy entitled Weighing Procedure revealed .The nursing assistant is responsible for weighing all residents .If a resident has a difference in weight of plus or minus five pounds at the time of weighing, the nursing assistant will reweigh the resident within twenty-four hours. The nursing assistant is to notify the charge nurse immediately. The charge nurse will assess the resident and initiate interventions as needed which may include notifying the physician or nurse practitioners the dietitian, family and care plan team. Weights and reweights are to be documented in the patients medical record . Review of a facility policy entitled Documentation Guidelines revealed .Weights: should be recorded on the appropriate form. 1) Time frames a) Weekly for 4 weeks following admission. b) At least monthly, unless ordered on a more frequent schedule by the physician, nurse, or dietitian .3) Any unusual variation in weights should be verified by re-weighing the patient. a) Document the results. b) If unusual variation still exists, report to licensed nurse, who reports to physician . Interview on November 20, 2013, at 10:14 a.m., with the resident in the resident's room, revealed the resident was aware of the admission weight of 161 pounds and had told the staff (resident) had not weighed that much in many years and .didn't believe it (the admission weight) was right . Further interview revealed the resident clothes fit the same from admission to the current date. Interview on November 20, 2013, at 10:20 a.m., with Certified Nurse Aide (CNA) #1, in the resident's room, confirmed CNA #1 admitted the resident and noticed no difference in the residents weight from admission to the current time. Further interview revealed the CNA noticed no difference in the way the clothes fit the resident. Interview on November 20, 2013, at 10:39 a.m., in the Registered Dietitian (RD) office, with the Director of Nursing and RD, confirmed the facility failed to weigh the resident weekly after admission and failed to reweigh the resident after the weight discrepancy per facility policy.	2017-05-01
8683	ADAMSPLACE, LLC	445392	1927 MEMORIAL BOULEVARD	MURFREESBORO	TN	37129	2013-11-20	371	F	0	1	GOZW11	Based on observation and interview, the facility failed to store food under sanitary conditions and failed to maintain a clean and sanitary kitchen. The findings included: Observation on November 18, 2013, at 7: 20 p.m., in the kitchen revealed on the shelving unit next to the steam table: 1. An unsealed open package of Quick Oats. 2. Two unsealed and opened packages of Creme of Wheat. 3. An unsealed and opened package of Grits. 4. An unsealed and opened box of baking soda. 5. An unsealed and opened package of Creole Seasoning. 6. An unsealed and opened package of White Rice. 7. An unsealed and opened package of Brown Rice. 8. One bottle of Heinz 57 Sauce with the cap opened. Further observation in the kitchen on August 18, 2013, at 7:30 p.m.,revealed: 1. The third bin of the steam table had food debris floating in the water. 2. In the walk-in refrigerator a pan of partially cooked pork tips was not fully covered or sealed with plastic wrap and the meat was exposed. Stored on top of and touching the partially cooked pork tips was a fully cooked pork wrapped in foil. 3. Two convection ovens with dark brown flaky debris on the interior. 4. A deep fryer filled with black oil uncovered with debris floating on the top of the oil. Interview with dietary personnel #1 on November 18, 2013, at 7:40 p.m., in the dietary office confirmed the facility failed to store food properly and maintain a clean and sanitary kitchen.	2017-05-01
8684	ADAMSPLACE, LLC	445392	1927 MEMORIAL BOULEVARD	MURFREESBORO	TN	37129	2013-11-20	441	D	0	1	GOZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain clean oxygen concentrator filters for one resident (#217) of twenty residents reviewed. The findings included: Resident #217 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician orders [REDACTED].oxygen per nasal cannula at 2-3 liters to keep saturation greater than 88 percent . Observation on November 19, 2013, at 8:36 a.m., in the resident's room revealed the resident in bed with a nasal cannula in place and the oxygen concentrator in operation. Further observation revealed both filters on the oxygen concentrator were white with debris. Interview, on November 20, 2013, at 8:36 a.m., with Registered Nurse #1, in the resident's room, confirmed both oxygen concentrator filters were dirty. Further interview confirmed they should have been cleaned.	2017-05-01
8685	ADAMSPLACE, LLC	445392	1927 MEMORIAL BOULEVARD	MURFREESBORO	TN	37129	2013-11-20	456	D	0	1	GOZW11	Based on observation and interview, the facility dietary department failed to maintain a pressure steamer in safe operational condition and created a safety hazard for dietary employees. The findings included: Observation on November 20, 2013, at 7:30 a.m., in the dietary department revealed an approximately four inch wide stream of water from the pressure steamer running on the floor to the trayline in operation. Further observation revealed dietary staff walking in and through the area of the water. Interview on November 20, 2013, at 7:30 a.m., with the dietary chef present during the observation, revealed the pressure steamer had .been leaking a long time . Interview on November 20, 2013, at 7:45 a.m., with the Certified Dietary Manager, by the pressure steamer, confirmed the steamer was leaking onto the floor and the water was crossing the floor to the trayline area.	2017-05-01
10756	ADAMSPLACE, LLC	445392	1927 MEMORIAL BOULEVARD	MURFREESBORO	TN	37129	2012-10-24	241	D	0	1	W8Q911	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to ensure staff asked permission or knocked on doors before entering resident rooms for two residents (#236, #242) of thirty- six sampled residents. The findings included: Resident #236 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated October 16, 2012, revealed identified problems areas of impaired vision, balance, and inability to ambulate. Medical record review of the Nurse's Note dated October 21, 2012, revealed alert and oriented. Medical record review of a psychosocial assessment dated [DATE], revealed the resident was cognitively intact. Observation on October 23, 2012, at 7:40 a.m., in the hallway, revealed Registered Nurse (RN) #1 entered the resident's room without knocking or obtaining permission to enter. Interview with RN #1 on October 23, 2012, at 9:45 a.m., in the 1200 hallway, confirmed the nurse failed to respect the resident's private space and failed to knock and request permission to enter the resident's room. Resident # 242 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated October 18, 2012, revealed the resident had impaired functional mobility and was at risk for musculoskeletal discomfort. Medical record review of an Admission note dated October 19, 2012, revealed the resident was alert and oriented. Observation on October 23, 2012, at 7:48 a.m., in the resident's room, revealed Registered Nurse (RN) #1 entered the resident's room without knocking or obtaining permission to enter. Interview with RN #1 on October 23, 2012, at 9:45 a.m., in the 1200 hallway, confirmed the nurse failed to respect the resident's private space and failed to knock and request permission to enter the resident's room.	2016-05-01
10757	ADAMSPLACE, LLC	445392	1927 MEMORIAL BOULEVARD	MURFREESBORO	TN	37129	2012-10-24	278	D	0	1	W8Q911	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to provide accurate information for the Minimum Data Set (MDS) assessment for one resident (#30) of thirty-seven residents reviewed. The findings included: Resident #30 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Dietary Progress Note dated May 28, 2012, revealed the resident had a gastrostomy feeding tube, and received nothing by mouth (NPO). Medical record review of the admission MDS dated [DATE], revealed the resident required extensive assist of one person for eating, and received 51% or more percent intake by artificial route (gastrostomy tube feeding). Medical record review of the 30 day MDS dated [DATE], revealed the resident was dependent on staff for eating. Continued review revealed the resident received 51% or more percent intake by artificial route (gastrostomy feeding tube). Interview with the MDS Coordinator in the private dining room on October 24, 2012, at 9:55 a.m., confirmed the resident had received nothing by mouth, and nutritional support had been provided through the use of the feeding tube. Continued interview confirmed the resident's 5 day/Admission MDS dated [DATE], was inaccurate.	2016-05-01
10758	ADAMSPLACE, LLC	445392	1927 MEMORIAL BOULEVARD	MURFREESBORO	TN	37129	2012-10-24	323	D	0	1	W8Q911	Based on observation and interview, the facility failed to secure soiled and biohazardous materials from the resident population. The findings included: Observation during initial tour on October 22, 2012, at 10:00 a.m., revealed a Certified Nurse Assistant (CNA) entered the soiled utility room and discarded soiled linen into containers. Continued observation revealed the door to the soiled utility room did not latch after the CNA entered the room to dispose of soiled linens. Observation on October 22, 2012, at 10:05 a.m., with Licensed Practical Nurse #2 (LPN), revealed LPN #2 attempted to restore the door to the locked position, but was unable to engage the latch. Interview with LPN #2 on October 22, 2012, at 10:05 a.m., confirmed the soiled utility room contained soiled linens and biohazard containers. Continued interview confirmed the door was not working properly, and should have latched and locked automatically when closed.	2016-05-01
10759	ADAMSPLACE, LLC	445392	1927 MEMORIAL BOULEVARD	MURFREESBORO	TN	37129	2012-10-24	356	D	0	1	W8Q911	Based on observation and interview, the facility failed to post nurse staffing data on a daily basis. The findings included: Observation on October 22, 2012, at 10:45 a.m., revealed the posted nurse staffing data was dated October 16, 2012. Observation and interview at this time with the Assistant Director of Nursing , in the skilled nurse's station, revealed the last posted nurse staffing data was on October 16, 2012, and confirmed the nurse staffing data was not posted for October 22, 2012.	2016-05-01
10760	ADAMSPLACE, LLC	445392	1927 MEMORIAL BOULEVARD	MURFREESBORO	TN	37129	2012-10-24	372	D	0	1	W8Q911	Based on observation and interview, the facility failed to maintain the exterior dumpster area in a sanitary manner. The findings included: Observation on October 22, 2012, at 10:00 a.m., with the Certified Dietary Manager (CDM) present, revealed two exterior dumpsters with several pieces of a broken watermelon shell and pink and green debris on the concrete surface in front of the dumpsters. Interview with the CDM on October 22, 2012, at 10:00 a.m., by the exterior dumpsters, confirmed the concrete in front of the dumpsters had pieces of watermelon shell and pink and green debris present and should maintain a clean dumpster area. Observation on October 24, 2012, at 9:40 a.m., with the CDM present, revealed watermelon shell and pink and green debris present on the concrete in front of both exterior dumpsters. Further observation revealed paper plates, napkins, straws, and styrofoam cups on the concrete surface behind the dumpsters. Interview with the CDM on October 24, 2012, at 9:40 a.m., by the exterior dumpsters, confirmed the concrete surface in front of the dumpsters contained watermelon shell, pink and green debris, and paper debris behind the dumpsters.	2016-05-01
10761	ADAMSPLACE, LLC	445392	1927 MEMORIAL BOULEVARD	MURFREESBORO	TN	37129	2012-10-24	441	D	0	1	W8Q911	Based on observation, facility policy review, and interview, the facility failed to ensure staff washed hands after medication administration; and failed to maintain infection control during blood glucose monitoring for two residents (#236, #228) of four residents reviewed for blood glucose monitoring of thirty-six sampled residents. The findings included: Observation of a medication administration on October 24, 2012, at 8:35 a.m, revealed Licensed Practical Nurse #1 (LPN) administered medications to resident #224. Continued observation revealed after the LPN administered the medications, returned to the medication cart, retrieved a stethoscope and proceeded to resident #234's room without washing the hands. Interview on October 24, 2012, at 9:00 a.m., with LPN #1, in the hallway, confirmed the nurse failed to wash the hands after administering the medications and prior to entering the resident's room Observation on October 23, 2012, at 7:40 a.m., on the 1200 hallway, revealed Registered Nurse (RN) #1 retrieved a blood glucose monitor from the medication cart, entered resident #236's room, placed the glucose monitor on the bedside table without a protective barrier. Continued observation at this time revealed RN #1 performed a blood glucose test for the resident, exited the resident's room, and placed the blood glucose monitor on the medication cart. Observation on October 23, 2012, at 7:44 a.m., on the 1200 hallway, revealed Registered Nurse (RN) #1 retrieved a blood glucose monitor from a drawer of the medication cart and placed the glucometer on top of the cart. Continued observation at this time revealed RN #1 entered resident #228's room, placed the glucose monitor on the resident's food tray without a protective barrier, performed a blood glucose test for the resident, exited the room, and placed the blood glucose monitor on the medication cart. Review of facility policy, Maintaining Glucometer, revealed .infection control standards will be maintained . Interview with RN #1 on October 23, 2012, at 7:45 a.m., on the 1200 hallway, confirmed a protective barrier was to be placed under the blood glucometer. Interview with the Assistant Director of Nursing (ADON) on October 23, 2012, at 9:30 a.m., in the ADON Office, revealed the staff complete a competency checklist and are instructed to use a protective barrier when performing blood glucose monitoring to prevent cross contamination. Continued interview confirmed the nurse failed to follow infection control standards when completing blood glucose tests.	2016-05-01
13381	ADAMSPLACE, LLC	445392	1927 MEMORIAL BOULEVARD	MURFREESBORO	TN	37129	2011-05-11	371	F	0	1	7FV811	Based on observation and interview the facility failed to maintain the dietary equipment in a sanitary manner. The findings included: Observation on May 9, 2011, beginning at 9:45 a.m., with the executive chef present, revealed the following: 1.) The four burner range top spill pan was foil lined with a heavy greasy layer of burnt black debris under the foil and on the surface of the foil. 2.) The four burner range back splash had an area of black burnt debris present. 3.) The four burner range had a grill. The left side and the rear of the grill surface had an accumulation of blackened debris present. 4.) The six burner range back splash had an accumulation of blackened debris present. Interview on May 9, 2011, beginning at 9:45 a.m., with the executive chef, confirmed the four burner range top spill pan had a heavy greasy layer of burnt black debris under the foil and on the surface of the foil that lined the spill pan. Further interview confirmed the four burner range back splash had an area of black burnt debris. Further interview confirmed the left side and the rear of the grill surface had an accumulation of blackened debris on the four burner range unit. Further interview confirmed the six burner range back splash had an accumulation of blackened debris.	2015-02-01
13382	ADAMSPLACE, LLC	445392	1927 MEMORIAL BOULEVARD	MURFREESBORO	TN	37129	2011-05-11	425	D	0	1	7FV811	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, pharmacy record review, and interview, the facility pharmaceutical service failed to dispense the quantity of Coumadin required for one resident (#6) of eighteen resident records reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician order [REDACTED]. Medical record review of the physician telephone order dated April 29, 2011, revealed "...Coumadin 7.5 mg po on Tuesday, Thursday, Saturday, Sunday..." Review of the pharmacy Fill History Form revealed the pharmacy dispensed ten doses of Coumadin 7.5 mg on April 22, 2011. Further review revealed the ten doses would meet the patient's needs for April 22 through May 3, 2011, per physician orders. Interview by speaker phone with Licensed Practical Nurse #1 (LPN) on May 10, 2011, at 2:35 p.m., with the facility unit manager and Director of Nursing present revealed LPN #1 did not have Coumadin 7.5 mg available in the medication cart for May 5 and 7, 2011. Further interview confirmed LPN #1 had not notified the pharmacy of the lack of medication. Interview by speaker phone with the LPN #2 on May 10, 2011, at 11:45 a.m., with the facility unit manager present revealed LPN #2 did not have Coumadin 7.5 mg available in the medication cart for May 8, 2011. Further interview confirmed LPN #2 had not notified the pharmacy of the lack of medication. Interview with the Director of Nursing on May 11, 2011, at 7:40 a.m., in the private dining room confirmed the pharmacy failed to dispense the quantity of Coumadin necessary to meet the patient's need as ordered by the physician.	2015-02-01
14325	ADAMSPLACE, LLC	445392	1927 MEMORIAL BOULEVARD	MURFREESBORO	TN	37129	2013-11-20	246	D			GOZW11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, the facility failed to maintain a call light within reach for one resident (#223) of twenty residents reviewed. The findings included: Resident #223 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated November 11, 2013, revealed the resident had a potential for falls/injury related to history of falls, decreased mobility, weakness, with the approach to keep the call light within reach. Observation and interview with the resident, on November 19, 2013, at 8:26 a.m. revealed the resident seated in a wheelchair in the resident's room with the breakfast tray on the over bed table in front of the resident. Further observation revealed the call light was on the bed side table directly behind the wheelchair and out of reach of the resident. Interview with the resident revealed the resident was not able to reach the call light. Interview on November 20, 2013, at 8:30 a.m., with the resident's direct care Certified Nurse Aide #1, in the resident's room, confirmed the resident was capable of using the call light. Further interview confirmed the call light was not in reach of the resident.	2014-01-01
2381	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2018-02-01	550	D	0	1	YE7V11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to promote a resident's dignity while providing personal care for 1 of 22 (Resident #74) sampled residents. The findings included: The facility's Quality of Life -Dignity policy documented, .Bodily Privacy During Care and Treatment .Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #74's room on 1/30/18 at 1:04 PM, revealed Certified Nursing Assistant (CNA) #1 entered the room, removed the resident's brief, turned and repositioned the resident. CNA #1 left Resident #74 fully exposed, with no cover. CNA #1 did not request permission from the resident to proceed with personal care. Interview with the Director of Nursing (DON) on 2/1/18 at 1:35 PM, in the conference room, the DON was asked if it was acceptable for a CNA to leave a resident fully exposed during personal care. The DON stated, No.	2020-09-01
2382	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2018-02-01	690	D	0	1	YE7V11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to ensure services were provided as ordered for the care of an indwelling urinary catheter for 1 of 1 (Resident #59) sampled residents reviewed for indwelling urinary catheters. The findings included: Medical record review revealed Resident #59 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment, and the presence of an indwelling urinary catheter. The physician's orders [REDACTED].Cath (catheter) care (with)soap et (and) H2O (water) q (every) shift . Observations in Resident #59's room on 1/28/18 at 4:40 PM, revealed Certified Nursing Assistant (CNA) #3 performed catheter care for Resident #59 using plain water. CNA #3 then retrieved a urinal containing a small amount of yellow liquid and emptied the catheter drainage bag into the urinal. CNA #3 tapped the spigot of the urinary drainage bag on the inside of the urinal during drainage. Interview with the Director of Nursing (DON) on 2/1/18 at 9:10 AM, in the conference room, the DON was asked what she expected staff to use for catheter care. The DON stated, Soap and water. The DON confirmed plain water was not acceptable.	2020-09-01
2383	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2018-02-01	693	D	0	1	YE7V11	Based on Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach Third Edition, observation and interview, the facility failed to ensure management of a tube feeding was preformed by qualified personnel for 1 of 1 (Resident #74) residents reviewed with a feeding tube. The findings included: Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach Third Edition page 110, documented, Nursing Intervention for People Receiving Enteral Nutrition. In caring for people with tube feedings, it is the nurse's responsibility to .administer the correct amount and type of feeding at the correct rate . Observations in Resident #74's room on 1/30/18 at 1:04 PM, revealed Certified Nursing Assistant (CNA) #1 entered the resident's room to turn and reposition the resident. CNA #1 immediately went to the feeding pump and put it on hold. When CNA #1 completed resident care, she reumed the feeding pump. Interview with the Director of Nursing (DON) on 2/1/18 at 1:35 PM, in the conference room, the DON was asked if it was acceptable for a CNA to put a feeding pump on hold and then resume the feeding. The DON stated, No	2020-09-01
2384	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2018-02-01	812	F	0	1	YE7V11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by improper storage of food in a cooler, expired food products, and a dirty deep fat fryer. The facility had a census of 79 with 77 of those residents receiving a meal tray from the kitchen. The findings included: Observations in the kitchen on [DATE] beginning at 8:00 AM, revealed the following: (a) 1 large package of bologna with an opening in the side of the package. Interview with the Certified Dietary Manager (CDM) on [DATE] at 8:15 AM, in the kitchen, the Dietary Manager confirmed the integrity of the package of bologna was broken. Observations in the kitchen on [DATE] beginning at 11:10 AM, revealed the following: (a) 2 cartons of fat free milk dated [DATE] in the milk cooler. (b) 1 carton of fat free milk dated [DATE] in the milk cooler. (c) 2 bottles of protein beverages dated [DATE] in the milk cooler. Interview with the CDM on [DATE] at 11:13 AM, in the kitchen, the CDM confirmed the milk and protein beverage were out of date and stated, .I know they are not supposed to be in there. (d) The deep fat fryer had black grease and food particles on top of the grease. Interview with the CDM on [DATE] at 11:16 AM, in the kitchen, the CDM was asked if the deep fat fryer was dirty. The CDM stated, It is due to be changed . (e) 1 container of vanilla pudding with an use by date of [DATE] in the reach-in cooler. Interview with the CDM on [DATE] at 11:20 AM, in the kitchen, the CDM stated,That should have gone out. The CDM removed it from the cooler. Observations in the kitchen on [DATE] at 11:17 AM, revealed the following : (a) The deep fat fryer had black grease with food particles on top of the grease. Interview with the CDM on [DATE] at 11:19 AM, in the kitchen, the CDM was asked if the deep fat fryer was dirty. The CDM stated, Yes, ma'am it is dirty . Interview with the CDM on [DATE] at 11:19 AM, in the dry food storage area, the CDM was asked if it was acceptable to have expired milk in the milk cooler. The CDM stated, No, ma'am. The CDM was asked if it was acceptable to have out dated protein beverages in the milk cooler. The CDM stated, No ma'am. The CDM was asked if it was acceptable for pudding with an expired use by date to be stored in the cooler. The CDM stated, No, ma'am. The CDM was asked if it was acceptable for bologna to be stored in a plastic bag with an opening in the side of the bag. The CDM stated, No ma'am.	2020-09-01
2385	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2018-02-01	880	D	0	1	YE7V11	Based on policy review, observation, and interview, the facility failed to ensure 1 of 4 (Licensed Practical Nurse (LPN #1) nurses followed practices to prevent the potential spread of infection during medication administration. The findings included: The facility's Equipment Cleaning, Disinfecting and Maintenance policy documented, .The following equipment is cleaned/disinfected after each resident use and when visibly soiled (the list includes examples of multi-use items .Stethoscopes .after use . Observations in Resident #74's room on 1/31/18 at 1:14 PM, revealed LPN #1 went to the medication cart, retrieved a stethoscope, placed the stethoscope around her neck and returned to the bedside. LPN #1 placed the stethoscope on the Resident #74's abdomen, administered medication, and laid the stethoscope on the unsanitized overbed table. Then LPN #1 left the room, carried the stethoscope and laid it on the top of the unsanitized medication cart. LPN #1 did not clean the stethoscope before or after use. Interview with the Director of Nursing (DON) on 2/1/18 at 1:37 PM, in the conference room, the DON was asked should a stethoscope be cleaned before or after administering Percutaneous Endoscopic Gastrostomy (PEG) medications. The DON stated, Yes.	2020-09-01
2386	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-07-16	600	J	1	0	98W311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on policy review, facility investigation review, medical record review, and interview, the facility failed to prevent neglect for 1 of 4 (Resident #1) sampled residents reviewed with wandering/exit seeking behaviors which resulted in Immediate jeopardy (IJ) when Resident #1 exited the facility, crossed 2 side streets, and walked to a local grocery store, 0.7 miles from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility neglected to ensure a safe environment for Resident #1 which placed Resident #1 in Immediate Jeopardy (IJ), The facility neglected to adequately supervise Resident #1, a cognitively impaired resident with known wandering and exit seeking behaviors. Resident #1 had a history of [REDACTED]. The resident exited the facility on 6/28/19 and was located 0.7 miles from the facility at a local grocery store. The facility had no knowledge the resident was missing until the resident was returned to the facility by the police. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600 was cited at a scope and severity of [NAME] F-600 J is Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: Review of the facility's Abuse Prevention Policy & Procedure revised 1/23/17 documented, .the right to be free from .neglect .Neglect: The failure to fulfill a care-taking obligation to provide goods or services necessary to avoid physical harm, mental anguish or mental illness . Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] from a Geriatric Psychiatric Unit with [DIAGNOSES REDACTED]. Resident #1 resided on the Secure Unit in the facility. Closed medical record review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/8/19 revealed Resident #1 was assessed with [REDACTED]. The MDS documented Resident #1 had disorganized thinking, inattention, delusions, verbal behaviors, physical behavior symptoms 1-3 days during the assessment period, impaired vision, and wore corrective lens. These behaviors placed the resident at significant risk for physical injury or illness. The resident was unsteady when ambulating. There were no Nursing Risk Assessments completed after the resident was admitted on [DATE] and readmitted on [DATE] to alert staff that Resident #1 was an elopement risk. Closed medical record review of the quarterly MDS with an ARD of 6/12/19 revealed Resident #1 was assessed to have a BIMS score of 7 which indicated the resident was severely impaired for decision making, had hallucinations, other behavioral symptoms, and the wandering behavior occurred 1 to 3 days. The resident did not require any assistive devices and needed limited assistance with walking. Closed medical record review of Resident #1's comprehensive care plan dated 3/12/19 and reviewed 6/20/19 revealed Resident #1 had wandering tendencies and exit seeking behaviors due to Dementia. Interventions to address this behavior included placing the resident in an area where frequent observation was possible, to implement facility protocol for locating an eloped resident, designate staff to account for resident's location throughout the day, and alert staff to the wandering behaviors. Interview with the Administrator on 7/11/19 at 7:30 PM in the Administrator's Office, the Administrator was asked if Resident #1 had exited the facility unattended prior to 6/28/19 and the Administrator stated, .I believe he got out .but not off of the premises .didn't investigate . Interview with Licensed Practical Nurse (LPN) #1 on 7/12/19 at 1:38 PM in the Conference Room, LPN#1 confirmed Resident #1 had exited the Secure Unit without staff being aware on 5/20/19. Review of a nurses' note dated 6/28/19 at 6:00 PM documented .continued exit-seeking behavior noted. Resident waving out window for help, standing at door until it opens in attempt to leave, and attempting to call on nurses' station phone w/o (without) permission. Will monitor behaviors . Review of the Resident Incident Report provided by the facility dated 6/28/19 revealed Resident #1 was confused and disoriented. The (named grocery store) employee notified the police department at 7:11 PM that the resident was in the store parking lot. The police returned the resident to the facility at 8:00 PM. Review of a nurses' note dated 6/29/19 at 6:03 AM documented, .at 2000 (8:00 PM on 6/28/19) resident was returned to hall when brought back to facility by police after elopement .stated 'I just followed some man out' . Interview with the Administrator on 7/11/19 at 3:50 PM in the 100 Hall, the Administrator stated, .I was here that day (6/28/19) .I was leaving to go home .I walked outside and saw 2 police officers standing outside talking. I waved at them and went to my car. It was between 7 (7:00 PM) and 8 (8:00 PM) that night .I called into the facility and they said the police had just brought (Resident #1) back to the facility from (named grocery store) .the only thing we can figure out is he walked out of the exit door on secure unit with a family member .we are unable to determine which route he took to the grocery store .I treated this like a jeopardy .my first question was how did they (staff) not know he was gone . Interview with the DON on 7/11/19 at 5:40 PM in the Conference Room, the DON was asked about Resident #1. The DON stated, .wandering .saw him at the door .around shift change stand by the door (on 6/28/19) . Interviews on 7/12/19 throughout the day with LPN #2, CNA #1, CNA #2, and Activity Assistant #1, all confirmed that on 6/28/19 Resident #1 exhibited exit seeking behavior, seemed more focused on exiting the facility, and seemed more agitated. Telephone interview with LPN #3 on 7/12/19 at 5:03 PM, LPN #3 revealed Resident #1 was .very aggressive at times .watches the doors .push on doors .watch people coming in and out through the doors .hadn't been back long from geri (geriatric)-psych (psychiatric) . LPN #3 was asked about the evening of 6/28/19 when he exited the facility. LPN #3 stated, .he wasn't in the lobby when I came on shift. He sometimes goes to bed after supper so I thought he was in bed .day shift had reported he was exit seeking that day .I had started med (medication) pass .around 8:00 PM. The 100 hall nurse (LPN # 4) brought Resident #1 in through the door (of the Secure Unit). The police had just returned him to the facility. His daughter was with him .he (Resident #1) stated, 'I went for a walk and had to find someone to bring me back' . LPN # 3 further stated .He was very, very determined .very sneaky .watching us go in and out of door . Interview with the Administrator and the DON on 7/13/19 at 5:04 PM in the Conference Room, the DON was asked how sending Resident #1 to a geri-psych facility addressed his exit seeking behavior and the DON stated, .adjusting his medications adding or decreasing and giving us other interventions that might help . The DON was asked if the staff should have been aware if a resident was missing from the facility for over an hour. The DON stated, .he wasn't gone that long . The Administrator was asked if the nurse responsible for the care of Resident #1 the evening of 6/28/19 was unaware the resident was missing from the facility prior to the police returning the resident to the facility at 8:00 PM. The Administrator stated, .yes that's true . The Administrator was asked if the employee at (Named grocery store) had not called 911 what could have happened to Resident #1. The Administrator stated, .I don't know .don't want to think about it . Interview with the Administrator, Regional Consultant for Clinical Services, and DON on 7/14/19 at 12:08 PM in the Conference Room, the Regional Consultant for Clinical Services stated, .the care plan was reviewed and updated .medications were changed .he was sent to geri-psych hospital. That is an intervention on his care plan and the activity was updated on 6/20/19 I don't think this meets criteria for an IJ . Interview with LPN #4 on 7/14/19 at 6:15 PM in the Conference Room, LPN #4 was asked about the night Resident #1 exited the facility and was located at a local grocery store, LPN #4 stated, .it was around 8:00 PM. The police walked down the 100 hall with Resident #1 and I assisted Resident #1 back to the Secure Unit . LPN #4 was asked if she was aware a resident was missing from the facility, LPN #4 stated, .no . Interview with the Regional Consultant for Clinical Services on 7/15/19 at 5:05 PM in the Conference Room, the Regional Consultant for Clinical Services was asked if the occurrence when Resident #1 exited the Secure Unit on 5/20/19 was documented on the 24 hour nurse report, the Regional Consultant for Clinical Services stated, .he did not actually leave so we did not consider that an incident .it's documented highly exit seeking behaviors noted . Interview with the DON on 7/16/19 at 5:23 PM in the Conference Room, the DON was asked if a resident should leave the Secure Unit unattended. The DON stated, .no The DON was asked if the staff should be unaware a resident was missing from the facility until the police returned the resident to the facility. The DON stated, .no . The facility's failure to supervise Resident #1, failure to respond to Resident #1's exit seeking behavior, and failure to know where Resident #1 was for 1 hour and 20 minutes resulted in neglect when Resident #1 eloped from the facility on 6/28/19 with a recorded high temperature of 86 degrees, crossed 2 side streets, and walked 0.7 miles to a local grocery store which was located 247 feet from a major 4 lane highway. Refer to F 689 The surveyor verified the A[NAME] by: 1. Head counts of all residents on the Secure Unit will be conducted by Licensed Nurses hourly on the Head Count Form. This was initiated on 7/15/19. The surveyor reviewed the Head Count Form and interviewed staff on each shift. 2. Active Exit-Seeking policy was updated on 7/14/19 to reflect definition and actions to take when residents are actively exit seeking. 100% of staff, which included all departments, will be in-serviced by the DON and/or Designee on updated policy by 7/15/19. Staff unable to attend this in-service will not be allowed to work until in-serviced. Changes included to the policy included: the definition of active exit seeking, if staff observes a resident actively exit seeking they are to stay with resident at all times, inform the Charge Nurse or Director of Nursing, utilize all of the care plan interventions currently in place, the charge nurse will complete a skilled nursing assessment to determine potential causes of behavior and will ensure the resident is on documented 1:1 immediately and complete an updated Elopement Risk Assessment and update the care plan with appropriate and new interventions. Resident will remain on 1:1 until an evaluation is completed by the Interdisciplinary Team and a determination is made the resident no longer requires the 1:1. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 3. Director of Nursing and/or Designee will educate all licensed and registered nurses on the Elopement Risk Assessment, the Nursing Summary. Staff unable to attend will not be allowed to work until in-serviced. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 4. Maintenance Director or Designee began elopement drills on each shift beginning 6/28/19 then weekly for four weeks then one shift weekly for two months and/or when substantial compliance is achieved. The surveyor reviewed the audits. 5. Beginning 6/28/19 the DON, Staff Development Coordinator or Designee began to conduct audits of resident head counts at shift change for two weeks, then three times weekly for four weeks, then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audits. 6. Social Services Director or Designee will audit elopement books beginning 7/15/19 to ensure they are updated based on new and updated elopement risk assessments weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 7. Employee Relations Director or Designee will audit new hires beginning 7/15/19 to ensure they received elopement procedure training weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 8. Beginning 7/15/19 the DON and/or Designee will audit five elopement risk assessments weekly for four weeks then monthly for two months to ensure any exit seeking behaviors are care planned appropriately. The surveyor reviewed the audit forms. Noncompliance of F-600 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.	2020-09-01
2387	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-07-16	657	J	1	0	98W311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on policy review, closed medical record review, and interview the facility failed to ensure care plans were revised for 1 of 4 (Resident #1) sampled residents reviewed to include new interventions for wandering, exit seeking behaviors, and elopement after Resident #1 a cognitively impaired and vulnerable resident with vision impairment eloped from the Secure Unit. The facility's failure to update Resident #1's care plan with new interventions to address Resident #1's exit-seeking behavior resulted in Resident #1 leaving the facility and being found 0.7 miles away at a grocery store. This failure placed Resident #1 in Immediate Jeopardy. An Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-657 was cited at a scope and severity of [NAME] A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: 1. The facility's undated Care Plans-Comprehensive policy documented, .individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .develops and maintains a comprehensive care plan for each resident .Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed quarterly .care plan goals and objectives are defined .goals and objectives are reviewed and/or revised .significant change in the resident's condition .when the desired outcome has not been achieved .resident has been readmitted to the facility from a hospital/rehabilitation stay .nurse supervisor uses the care plan to complete the CNA's (Certified Nursing Assistant) daily work assignment sheets .CNA's are responsible for reporting to the nurse supervisor any changes in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved .changes in the resident's condition must be reported to the MDS (Minimum Data Set) Assessment Coordinator so that a review of the resident's assessment and care plan can be made .The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans .when the resident has been readmitted to the facility from a hospital stay . 2. The facility's undated Care Planning-Interdisciplinary Team policy documented, .development of an individualized comprehensive care plan for each resident .Prior to attending the care planning conference, each discipline will be responsible for developing a problem identification list .any area of difficulty or concern that prevents the resident from reaching his/her fullest potential. Problems must be stated .short-term goals must be resident oriented, behaviorally stated, measurable. Approach-The specific action (s) or intervention (s) that the staff will take to assist the resident in meeting/achieving the short-term goals . 3. Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Closed medical record review of the MDS dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status score of 7 which indicated Resident #1 was severely impaired cognitively. Closed medical record review of Resident #1's comprehensive care plan created on 3/12/19 documented, .3/12/19 .Has wandering tendencies and exit seeking behaviors at times d/t (due to) Dementia .Place resident in area where frequent observation is possible .Provide diversional activities .Redirect when wandering into other resident's rooms .Instruct visitors to inform staff when they are leaving the designated area with the resident .Implement facility protocol for locating an eloped resident .If wandering away from unit, instruct staff to stay with resident, converse and gently persuade to walk back to designated area with them . There were no new interventions implemented until 6/28/19. Closed medical record review revealed Resident #1 was admitted to the hospital from 5/21/19 to 6/6/19 due to increased confusion, aggression toward staff at facility, anxiety, and noted instability. Interview with the Administrator on 7/11/19 at 7:30 PM, in the Administrator's Office, the Administrator was asked had Resident #1 ever left the facility before. The Administrator stated, .I believe he got out of the Secure Unit but not off of the premises .didn't investigate . Interview with Licensed Practical Nurse (LPN) #1 on 7/12/19 at 1:38 PM, in the Conference Room, LPN #1 was asked about when Resident #1 had exited the Secure Unit without awareness of the staff. LPN #1 stated, .I know he got out the doors (400 hall doors) on the 100 side of the unit .it was in the evening maybe around 5-6 (5:00 PM-6:00 PM). I walked back to the nurses' station and (Named Clinical Manager #1) brought him in through the door of the Secure Unit .I know I wrote a nurse's note about him leaving the unit but it's gone .I'll go talk to (Named Clinical Manager #1) she was the nurse that brought him to the unit .she will know the date . LPN #1 returned a few moments later and stated, .I asked (Named Clinical Manager #1), she said it was (MONTH) 20th (5/20/19) . LPN #1 was asked if an incident report or an assessment was done. LPN #1 stated, .no I didn't do an incident report .just a head to toe assessment to be sure he was ok .and a nurses note which is gone . Interview with Clinical Manager #1 on 7/15/19 at 10:27 AM, in the Conference Room, Clinical Manager #1 was asked about when Resident #1 exited the Secure Unit to an unsecured area in the building. Clinical Manager #1 stated, .May 20th 2019 (5/20/19) .yes .possibly around 6 PM-7 PM (6:00 PM - 7:00 PM) .exit the Secure Unit through the 400 hall doors . Clinical Manager #1 was asked if there were any staff or visitors with the resident. Clinical Manager #1 stated, .no just him .he walked out the 400 hall doors and turned toward the 100 hall nurses station and started walking very fast toward the nurses station .I immediately escorted him back to the unit . Closed medical record review of the comprehensive care plan reviewed on 6/20/19 revealed there were no new interventions for the exit seeking behaviors that occurred on 5/20/19 when he was readmitted on [DATE]. Closed medical review of a Nurses' Note dated 6/28/19 at 6:00 PM documented, .continued exit seeking behavior noted. Resident waving out window for help, standing at door until it opens in attempt to leave and attempting to call on nurse station phone w/o (without) permission . Closed medical review of a Nurse's Note dated 6/29/19 at 6:03 AM documented, .at 2000 (8:00 PM on 6/28/19) resident was returned to hall when brought back to facility by police after elopement .resident stated 'I just followed some man out the door.' Told staff he just was going for a walk and got lost and knew he needed to find someone to take him back .checked on every 30 minutes throughout the night . Interview with MDS Coordinator #1 on 7/12/19 at 4:55 PM, in the Conference Room, MDS Coordinator #1 was asked who updated and initiated the care plans. MDS Coordinator #1 stated, .sometimes I do care planning but (Named MDS Coordinator #2) does most of it . MDS Coordinator #1 was asked if she attended the morning meetings. MDS Coordinator #1 stated, .yes .we go over the 24 hour nurse report book, go over incidents and orders that are written . MDS Coordinator #1 was then asked if Resident #1 had ever left the Secure Unit or the building. MDS Coordinator #1 stated, .I have no knowledge of him leaving the unit or the building . Interview with MDS Coordinator #2 on 7/13/19 at 9:43 AM, in the Conference Room, MDS Coordinator #2 was asked about the care plan process and who was involved. MDS Coordinator #2 stated, .we cover incident reports in the daily clinical meeting and update the care plans .the DON, the Administrator, Risk Management, (Named Clinical Manager #1) .the meetings are not held on the weekend. If it happens on the weekend it will be discussed Monday . MDS Coordinator #2 was asked if Resident #1 left the facility or the unit in (MONTH) (2019). MDS Coordinator #2 stated, .no .I don't recall that . MDS Coordinator #2 was asked if she had updated Resident #1's care plan. MDS Coordinator #2 stated, .I could have potentially updated the care plan . MDS Coordinator #2 was asked to review Resident #1's care plan and if there were any interventions related to Resident #1 exiting the Secure Unit in (MONTH) (2019). MDS Coordinator #2 stated, .No . Interview with the Administrator and the DON on 7/13/19 at 5:04 PM, in the Conference Room, they were asked what facility action was taken when Resident #1 exited the Secure Unit to an unsecured area of the building on 5/20/19. The Administrator stated, .codes changed on secure unit doors (corridor) and exit door of secure unit (to the outside) .sent him to (Named geriatric psychiatric facility) . The Administrator and DON confirmed there were no new interventions put into place after this exit seeking behavior. The facility failed to ensure that the care plan was revised to include new interventions to prevent elopement for a cognitively impaired resident with known exit seeking behaviors and a history of elopement. Refer to F600 and F689 The surveyor verified the A[NAME] by: 1. Active Exit-Seeking policy was updated on 7/14/19 to reflect definition and actions to take when residents are actively exit seeking. 100% of staff, which included all departments, will be in-serviced by the DON and/or Designee on updated policy by 7/15/19. Staff unable to attend this in-service will not be allowed to work until in-serviced. Changes included to the policy included: the definition of active exit seeking, if staff observes a resident actively exit seeking they are to stay with resident at all times, inform the Charge Nurse or Director of Nursing, utilize all of the care plan interventions currently in place, the charge nurse will complete a skilled nursing assessment to determine potential causes of behavior and will ensure the resident is on documented 1:1 immediately and complete an updated Elopement Risk Assessment and update the care plan with appropriate and new interventions. Resident will remain on 1:1 until an evaluation is completed by the Interdisciplinary Team and a determination is made the resident no longer requires the 1:1. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 2. Director of Nursing and/or Designee will educate all licensed and registered nurses on how to update care plans with appropriate interventions. Staff unable to attend will not be allowed to work until in-serviced. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 3. The DON and/or Minimum Data Set (MDS) Nurse will update care plans for residents with past exit seeking behaviors beginning 7/15/19. The surveyor reviewed the care plans. Noncompliance of F-657 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.	2020-09-01
2388	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-07-16	689	J	1	0	98W311	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on policy review, closed medical record review, and interview, the facility failed to ensure adequate supervision to prevent elopement for 1 of 4 (Resident #1) cognitively impaired, vulnerable, visually impaired residents who had wandering/exit seeking behaviors resulting in Immediate Jeopardy (IJ) for Resident #1. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility failed to ensure a safe environment and placed Resident #1 in Immediate Jeopardy (IJ) by failing to adequately supervise Resident #1, a cognitively impaired resident with prior wandering and exit seeking behaviors, who was missing for approximately 1 hour and 20 minutes before the staff realized he had eloped from the facility. Resident #1 was found by a customer wandering outside of a grocery store located 0.7 miles from the facility. This resulted in an IJ for Resident #1. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-689 was cited at a scope and severity of [NAME] F-689 J is Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: 1. The facility's Accident-Incident-Elopement-Wandering Resident undated policy documented, .every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for wandering/elopement .should a wandering/elopement episode occur, the contributing factors, as well as the interventions tried, will be documented on the resident's medical record and review by the interdisciplinary team .responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse . 2. Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Closed medical record review revealed there was no elopement risk assessment completed when Resident #1 was admitted to the facility on [DATE]. Closed medical record review of the Care Plan dated 3/12/19 and revised 6/28/19 revealed Resident #1 had wandering tendencies and exit seeking behaviors due to Dementia. The interventions included if wandering away from unit, instruct staff to stay with the resident, converse and gently persuade to walk back to designated area, place resident in an area where frequent observation is possible, provide diversional activities as needed, implement facility protocol for locating an eloped resident, designate staff to account for residents whereabouts throughout the day, alert staff to wandering behaviors, and approach wandering resident in a positive, calm, and accepting manner. Closed medical record review of the quarterly Minimum data Set (MDS) with an assessment reference date (ARD) of 6/12/19 revealed Resident #1 was assessed to have a BIMS of 7, which indicated severe cognitive impairment. The resident was visually impaired, had hallucinations and other behavioral symptoms not directed toward others which occurred 1 to 3 days of the assessment period. Resident #1 had wandering behaviors which occurred 1 to 3 days of the assessment period, needed limited assistance with walking, and required no assistive devices. Closed medical record review revealed Resident #1 was admitted to the hospital from 5/21/19 to 6/6/19 due to increased confusion, aggression toward staff at the facility, anxiety, and noted anxiety. The Psychiatric Evaluation dated 5/22/19 from this hospital stay documented, .Justification for hospitalization - Inpatient Failure or treatment at a lower level of care, hallucinations, delusions, agitation, anxiety, depression, resulting in a significant loss of functioning. Emotional or behavioral conditions and complications requiring 24 hour medical and nursing care. Failure of social or occupational functioning, Inability to meet basic life and health needs . Interview with the Administrator on 7/11/19 at 7:30 PM, in the Administrator Office, the Administrator was asked if Resident #1 ever left the facility prior to 6/28/19. The Administrator stated, .I believe he got out of the Secure Unit but not off of the premises . The Administrator was asked when this occurred and what interventions were implemented to address it. The Administrator stated, .about 3 months ago .I'll have to check .didn't investigate . Interview with Licensed Practical Nurse (LPN) #1 on 7/12/19 at 1:38 PM, in the Conference Room, LPN #1 was asked when Resident #1 exited the Secure Unit without awareness of the staff. LPN #1 stated, yes .I was the nurse the day he stepped out of the unit .I know he got out the doors (400 hall doors) on the 100 side of the unit .it was in the evening maybe around 5-6 (5:00 PM-6:00 PM) because I had went to the 300 hall to give medications. I walked back to the nurses' station and (Named Clinical Manager #1) brought him in through the door of the Secure Unit .was (MONTH) 20th . LPN #1 was asked if an incident report or an assessment was done. LPN #1 stated, .no I didn't do an incident report just a head to toe assessment to be sure he was ok . Interview with Clinical Manager #1 on 7/15/19 at 10:27 AM, in the Conference Room, Clinical Manager #1 was asked when Resident #1 exited the Secure Unit to an unsecured area in the building. Clinical Manager #1 stated, .May 20th 2019 (5/20/19) .yes .possibly around 6 PM-7 PM (6:00 PM-7:00 PM) .exit the Secure Unit through the 400 hall doors . Clinical Manager #1 was asked if there were any staff or visitors with the resident. Clinical Manager #1 stated, .no just him .he walked out the 400 hall doors and turned toward the 100 hall nurses station and started walking very fast toward the nurses station I immediately escorted him back to the unit . Review of Resident #1's medical record revealed there was no documentation of the incident on 5/20/19. There were no new interventions for the exit seeking behavior when the resident returned from the hospital on [DATE]. There was no investigation of the incident to determine how the resident left the Secured Unit. Closed medical record review revealed there was no elopement risk assessment completed when Resident #1 was readmitted to the facility on [DATE] from the hospital. Closed medical record review revealed documentation that Resident #1 displayed impaired cognitive status and exit seeking behaviors: a. A Nurse's Note dated 6/6/19 at 6:48 PM documented, .repetitive confusion noted with place. Periods of anxiety . b. Review of an Admission/Readmission Note dated 6/6/19 revealed Resident #1 had Chronic Repetitive Disruptive Behavior that could potentially cause harm to himself or other, Chronic Wandering Behavior and Hallucinations. c. A Nurse's Note dated 6/9/19 at 7:28 PM documented, .resident pulled fire alarm in dining room . d. A Nurse's Note dated 6/10/19 at 4:13 PM documented, .continues to ask where his (he is) at and who comes to see him . e. Review of a Long Term Care Observation nurses' note dated 6/14/19 revealed Resident #1 was anxious, agitated, had chronic repetitive behavior, and wandering that included wandering at night and hallucinations. Resident #1's current level of mental status was documented as severe impairment that affected all areas of judgment. f. Review of a Long Term Care Observation nurses' note dated 6/21/19 revealed Resident #1 had chronic repetitive behavior, short term memory loss, and was currently disorientated and confused. g. A Nurse's Note dated 6/28/19 at 6:00 PM documented, .continued exit seeking behavior noted. Resident waving out window for help, standing at door until it opens in attempt to leave, and attempting to call on nurses' station phone w/o (without) permission . h. A Nurse's Note dated 6/29/19 at 6:03 AM documented, .at 2000 (8:00 PM on 6/28/19) resident was returned to hall when brought back to facility by police after elopement .resident stated 'I just followed some man out the door.' Told staff he just was going for a walk and got lost and knew he needed to find someone to take him back .checked on every 30 minutes throughout the night . i. A Nurse's Note dated 6/29/19 documented, .start of shift (7:00 AM 6/29/19), resident watched one on one . Based on the National Weather Service records, the recorded high temperature for the facility area on 6/28/19 (the day of the elopement from the facility) was 86 degrees Fahrenheit. The facility is located near an abandoned factory, a public park, and a community center with public parking. Closed medical record review revealed Resident #1 was transferred to the psychiatric hospital on [DATE], after this elopement episode. Closed medical record review of the (Named Hospital) ADMISSION NURSING assessment dated [DATE] documented, .Reason for admission .per facility pt. (patient) having danger issues and has been combative and tries to elope .Has the patient been violent to others in the past 6 months? (Yes checked) . Behaviors .Other (checked) exit seeking .Potential for elopement (checked) . The History and Physical from this hospital stay dated 6/30/19 documented, .anger, agitated threatens to shoot people high elopement risk . 3. Interview with LPN #2 on 7/12/19 at 8:52 AM, in the Conference Room, LPN #2 was asked if Resident #1 had exited the building on 6/28/19. LPN #2 stated, .I work the 400 hall day shift .I worked day shift 7 AM-7 PM (7:00 AM-7:00 PM) .when he formulates a plan, he will execute it if he wants to get out .standing by the door, when someone was going out the door, he would try to talk to them, and try to go out behind them .he had left here and went to another facility but they couldn't handle his exit seeking, he got out of that facility while he was there .I talked to him the night he eloped about 6:20 PM .that was the last time I saw him that night .changed shift and went home . Interview with Certified nursing Assistant (CNA) #1 on 7/12/19 at 9:40 AM, in the Conference Room, CNA #1 stated, .(Resident #1) always watching the door, seemed to be more focused on who was coming in and out of door .that day in particular (6/28/19) he was waving at me out the window .I saw him about 6:40 PM leaned against the corner of the 400 hall near the exit door (to outside) . Interview with Activity Assistant #1 on 7/12/19 at 9:55 AM in the Conference Room, Activity Assistant #1 stated .(Resident #1) always exit seeking .seemed more agitated that day (6/28/19) . Interview with the police officer on 7/12/19 at 1:05 PM, at the (Named City) Police Department, the police officer was asked about the incident on 6/28/19. The police officer stated, .there is not a police report .just the 911 dispatch information .according to it (dispatch log) the call came in at 19:11 (7:11 PM) suspicious person .the person was confused and doesn't know where he is .sitting on bench out front .the officer arrived at 7:15 PM at the grocery store. I arrived at 19:26 (7:26 PM) .he was confused and seemed scared .I asked his name and where he was from .he told me his name and that he was from (Named city) .I asked some more questions about his family and I recognized his daughter's name. We have a mutual friend so I got on (Named social media website) to find the more information, contacted a friend and got in touch with his daughter .I took him back to the facility around 8:00 PM .(staff) didn't know a resident was missing from the nursing home . Interview with MDS Coordinator #2 on 7/13/19 at 9:43 AM, in the Conference Room, MDS Coordinator #2 was asked if Resident #1 left the facility or the unit in (MONTH) of 2019. MDS Coordinator #2 stated, .no .don't recall that . MDS Coordinator #2 was asked if she had updated Resident #1's care plan. MDS Coordinator #2 stated, .I could have potentially updated the care plan . MDS Coordinator #2 was asked to review Resident #1's care plan and if there were new interventions related to the resident exiting the Secure Unit in (MONTH) of 2019. MDS Coordinator #2 stated, .no .it was reviewed 6/20/19 . Telephone interview with the grocery store employee on 7/13/19 at 2:00 PM, the employee was asked what happened on 6/28/19. The employee stated, .it was later in the day .a regular customer came in the store and said there was a gentleman wandering around outside at the front of the store. The customer said you might want to call 911, so I did. We asked him his name and he told us, but we didn't know anyone to call. The police came and the officers asked who his children were .the officer got in touch with someone that knew the man's daughter the police put him in vehicle and left . Interview with the Administrator and the DON on 7/13/19 at 5:04 PM, in the Conference Room, they were asked what facility action was taken when Resident #1 exited the Secure Unit to an unsecured area of the building on 5/20/19. The Administrator stated, .codes changed on secure unit doors (corridor) and exit door of secure unit (to the outside) .sent him to (Named geriatric psychiatric facility) . The Administrator and DON confirmed there were no new interventions put in place after the exit seeking behavior on 5/20/19. The surveyor verified the A[NAME] by: 1. Door Code was immediately reset by the Maintenance Director on 6/28/19. 2. Signage was posted on the back exit door on the unit not to utilize door except in an emergency. Signage was posted on all other exit and corridor doors reminding visitors to be aware of others potentially exiting with them on 6/28/19. The signage was viewed by the surveyor on 7/16/19. 3. Maintenance Director checked all the windows on the Secure Unit to ensure that [MEDICATION NAME] were in place that limit the windows opening more than 4 inches on 6/28/19. This was confirmed by the surveyor through observations and interview on 7/16/19. 4. Head counts of all residents on the Secure Unit will be conducted by Licensed Nurses hourly on the Head Count Form. This was initiated on 7/15/19. The surveyor reviewed the Head Count Form and interviewed staff on each shift. 5. Active Exit-Seeking policy was updated on 7/14/19 to reflect definition and actions to take when residents are actively exit seeking. 100% of staff, which included all departments, will be in-serviced by the DON and/or Designee on updated policy by 7/15/19. Staff unable to attend this in-service will not be allowed to work until in-serviced. Changes included to the policy included: the definition of active exit seeking, if staff observes a resident actively exit seeking they are to stay with resident at all times, inform the Charge Nurse or Director of Nursing, utilize all of the care plan interventions currently in place, the charge nurse will complete a skilled nursing assessment to determine potential causes of behavior and will ensure the resident is on documented 1:1 immediately and complete an updated Elopement Risk Assessment and update the care plan with appropriate and new interventions. Resident will remain on 1:1 until an evaluation is completed by the Interdisciplinary Team and a determination is made the resident no longer requires the 1:1. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 6. Director of Nursing and/or Designee will educate all licensed and registered nurses on the Elopement Risk Assessment, the Nursing Summary and how to update care plans with appropriate interventions. Staff unable to attend will not be allowed to work until in-serviced. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 7. The DON and designee re-assessed all residents in the building to determine any residents with exit seeking behaviors on 6/28/19 and 6/29/19. Results were no new residents identified as an elopement risk or added to the list. The assessments were reviewed by the surveyor. 8. Housekeeping Director or Designee will audit doors daily beginning 7/15/19 to ensure signage is still in place for two weeks, then weekly for two months and/or substantial compliance is achieved. The surveyor reviewed the audit forms. 9. Maintenance Director or Designee began elopement drills on each shift beginning 6/28/19 then weekly for four weeks then one shift weekly for two months and/or when substantial compliance is achieved. The surveyor reviewed the audit forms. 10. Beginning 6/28/19 the DON, Staff Development Coordinator or Designee began to conduct audits of resident head counts at shift change for two weeks, then three times weekly for four weeks, then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 11. Beginning 6/28/19 Maintenance Director or Designee checked all windows in resident rooms and will continue on a monthly basis to ensure that [MEDICATION NAME] are in place to limit opening to 4-6 inches on an ongoing basis. This began on 6/28/19. 12. Social Services Director or Designee will audit elopement books beginning 7/15/19 to ensure they are updated based on new and updated elopement risk assessments weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 13. Employee Relations Director or Designee will audit new hires beginning 7/15/19 to ensure they received elopement procedure training weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 14. Beginning 7/15/19 the DON and/or Designee will audit five elopement risk assessments weekly for four weeks then monthly for two months to ensure any exit seeking behaviors are care planned appropriately. The surveyor reviewed the audit forms. 15. The DON and/or Minimum Data Set (MDS) Nurse will update care plans for residents with past exit seeking behaviors beginning 7/15/19. The surveyor reviewed the care plans. 16. On 7/15/19 results of the audits will be discussed at the Quality Assurance Performance Improvement Committee weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. Noncompliance of F-689 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.	2020-09-01
2389	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-07-16	835	J	1	0	98W311	> Based on the Administrator's Job Description, Director of Nursing (DON) Job Description, medical record review, and interview, the Administrator failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of residents. Administration failed to provide oversight and training of staff to prevent a cognitively impaired, vulnerable resident from eloping from the Secure Unit of the facility. The resident walked 0.7 miles to a local grocery store. The Administrator's failure to provide resident safety placed Resident #1 in Immediate Jeopardy when staff did not complete assessments related to elopement risks, investigate an incident when Resident #1 exited a Secure Unit of the facility to an unsecured area, failed to ensure Resident #1 was free from neglect, and failed to ensure a safe environment for Resident #1. An Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600, F-657, F-689, F-835, and F-865 were cited at a scope and severity of [NAME] F-600 J and F-689 J are Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: The Nursing Home Administrator job description with a revision date of 6/2006 documented.lead and direct the overall operations of the facility in accordance with .government regulations and Company policy, with focus on maintaining excellent care for the residents .This facility expects their employees to promote an atmosphere .hospitality and comfort for its residents .oversee regular rounds to monitor delivery of nursing care .ensure residents needs are being addressed .Maintain a working knowledge of and confirm compliance with all governmental regulations .improvement of services . The facility's Director of Nursing Job description with a revision date of 6/2006 documented, .manage the overall operations of the Nursing Department in accordance with .policies, standards of nursing practice and governmental regulations so as to maintain excellent care of all residents' needs .plan, develop, organize, implement, evaluate and direct the nursing services department .assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department .resident care of the nursing service department .participate in coordination of resident services .provide appropriate departmental in-service education .in compliance with .State and Federal Guidelines .complete investigative analysis .study .resident Incident Reports for corrective action .Keep Administrator informed on a daily basis of nursing department functions, recommending changes in techniques or procedures .efficient operation .Assure residents are comfortable, clean .safe environment .Verify that medical and nursing care is administered .assist with development of and approve final version of the Interdisciplinary Plan of Care for each resident .review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to care, and that such care is provided . Interview with the Administrator on 7/11/19 at 3:50 PM in the 100 Hall, the Administrator was asked about the incident when Resident #1 eloped. The Administrator stated, .I was here that day (6/28/19) .I was leaving to go home .I walked outside and saw 2 police officers standing outside talking. I waved at them and went to my car. It was between 7 (7:00 PM) and 8 (8:00 PM) that night .I called into the facility and they said the police had just brought (Resident #1) back to the facility from (named grocery store) .the only thing we can figure out is he walked out of the exit door on Secure Unit with a family member .we are unable to determine which route he took to the grocery store .I treated this like a jeopardy .my first question was how did they (staff) not know he was gone . The Administrator was asked if Resident #1 had ever eloped before. The Administrator stated, .he left the Secure Unit 1 time and he was found on the 100 hall .we didn't investigate it as an incident because he didn't leave the facility .no incident report . Administration failed to update Resident #1's Care Plan with new interventions for his exit seeking behavior. Refer to F657 Administration failed to ensure supervision of residents with wandering/exit seeking behaviors. Administration neglected to ensure staff were knowledgeable of the location of the residents with wandering/exit seeking behaviors when a resident exited the Secure Unit and was not identified as missing until the police returned the resident to the facility. Refer to F600 and F689. The surveyor verified the A[NAME] by: 1. Housekeeping Director or Designee will audit doors daily beginning 7/15/19 to ensure signage is still in place for two weeks, then weekly for two months and/or substantial compliance is achieved. The surveyor reviewed the audit forms. 2. Maintenance Director or Designee began elopement drills on each shift beginning 6/28/19 then weekly for four weeks then one shift weekly for two months and/or when substantial compliance is achieved. The surveyor reviewed the audit forms. 3. Beginning 6/28/19 the DON, Staff Development Coordinator or Designee began to conduct audits of resident head counts at shift change for two weeks, then three times weekly for four weeks, then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 4. Social Services Director or Designee will audit elopement books beginning 7/15/19 to ensure they are updated based on new and updated elopement risk assessments weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 5. Employee Relations Director or Designee will audit new hires beginning 7/15/19 to ensure they received elopement procedure training weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 6. Beginning 7/15/19 the DON and/or Designee will audit five elopement risk assessments weekly for four weeks then monthly for two months to ensure any exit seeking behaviors are care planned appropriately. The surveyor reviewed the audit forms. 7. On 7/15/19 results of the audits will be discussed at the Quality Assurance Performance Improvement Committee weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. Noncompliance of F-835 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.	2020-09-01
2390	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-07-16	865	J	1	0	98W311	> Based on review of the Administrator job description, review of the Director of Nursing (DON) job description, Quality Assurance (QA) Coordinator job description, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to exit seeking behavior assessments, completion of incident investigations, completion of elopement assessments, developing plans of action and interventions for exit seeking behaviors, failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns, and failed to ensure the facility was administrated in a manner that enabled it to use its resources effectively and efficiently. Failure of the QAPI Committee to ensure the facility implemented and/or provided new interventions related to active exit seeking, and that staff ensured a safe environment for residents placed 1 of 4 (Resident #1) sampled residents in Immediate Jeopardy when Resident #1, a cognitively impaired resident with known wandering and exit seeking behaviors, was missing for approximately 1 hour and 20 minutes before the staff realized he had eloped from the facility. Resident #1 was found by a customer when Resident #1 was wandering outside of a local grocery store located 0.7 miles from the facility. This resulted in an IJ for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600, F-657, F-689, F-835, and F-865 were cited at a scope and severity of [NAME] F-600 J and F-689 J are Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: The Nursing Home Administrator job description with a revision date of 6/2006 documented.lead and direct the overall operations of the facility in accordance with .government regulations and Company policy, with focus on maintaining excellent care for the residents .This facility expects their employees to promote an atmosphere .hospitality and comfort for its residents .ensure residents needs are being addressed .Maintain a working knowledge of and confirm compliance with all governmental regulations .improvement of services . The facility's Director of Nursing Job description with a revision date of 6/2006 documented, .manage the overall operations of the Nursing Department in accordance with .policies, standards of nursing practice and governmental regulations so as to maintain excellent care of all residents' needs .plan, develop, organize, implement, evaluate and direct the nursing services department .resident care of the nursing service department .participate in coordination of resident services .provide appropriate departmental in-service education .in compliance with .State and Federal Guidelines .complete investigative analysis .study .resident Incident Reports for corrective action .Keep Administrator informed on a daily basis of nursing department functions, recommending changes in techniques or procedures .efficient operation .Assure residents are comfortable, clean .safe environment .Verify that medical and nursing care is administered .assist with development of and approve final version of the Interdisciplinary Plan of Care for each resident .review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to care, and that such care is provided . Review of the QA Coordinator job description revised 6/2008 documented, .reports to Director of Nursing .supports successful implementation and maintenance of clinical and quality initiatives and protocols for use at the facility .to assure the facility is following .regulations .Identify deficit(s) related to policy/procedures and develop draft policy for review .identify weakness .of clinical initiatives to provide/promote resident well-being .new clinical initiatives to correct weaknesses .develop a detailed report on findings to report to QA Committee. Report any high risk areas immediately .staff .to provide accurate information and correct negative trends .Identifies Safety and Risk Management issues and communicates areas of weakness to Administrator .conduct meaningful weekly Quality Assurance meetings .weekly Quality Services department meetings .Protect residents from neglect . Interview with Clinical Manager #1 on 7/15/19 at 10:27 AM, Clinical Manager #1 was asked if she attended Interdisciplinary Team (IDT) Meetings. Clinical Manager #1 stated, .yes I attend the meetings . Clinical Manager #1 was asked if exit seeking behaviors were discussed in the meetings. Clinical Manager #1 stated, .I don't recall discussing exit seeking behavior or (discussing) him (Resident #1) leaving the Secure Unit in (MONTH) (2019) . Clinical Manager #1 was the staff member who saw Resident #1 leave the Secure Unit on (MONTH) 20, 2019. Interview with the QA Coordinator on 7/15/19 at 3:04 PM, in the Conference Room, the QA Coordinator was asked if any concerns related to behaviors and exit seeking behaviors had been identified. The QA Coordinator stated, .no . Interview with the QA Coordinator on 7/16/19 at 5:15 PM, in the Conference Room, the QA Coordinator was asked if the QA committee was effective. The QA Coordinator stated, .no .the things we put in place (indicating the A[NAME]) will help it to be better . 1. The facility's QA committee failed to identify areas of improvement related to active exit seeking behaviors. Refer to F600, F657, F689, F835 2. The facility's QA committee failed to identify an incident of elopement, failed to investigate the incident to determine the root cause of the incident, failed to identify appropriate plans of action, and failed to ensure new interventions related to the incident of elopement were added to the resident's care plan. Refer to F 600, F657, F689, F835 3. The facility's QA committee failed to identify that elopement risk assessments were not current and updated for residents of the facility's Secure Unit. Refer to F 600, F657, F689, F835 The surveyor verified the A[NAME] by: 1. Housekeeping Director or Designee will audit doors daily beginning 7/15/19 to ensure signage is still in place for two weeks, then weekly for two months and/or substantial compliance is achieved. The surveyor reviewed the audit forms. 2. Maintenance Director or Designee began elopement drills on each shift beginning 6/28/19 then weekly for four weeks then one shift weekly for two months and/or when substantial compliance is achieved. The surveyor reviewed the audit forms. 3. Beginning 6/28/19 the DON, Staff Development Coordinator or Designee began to conduct audits of resident head counts at shift change for two weeks, then three times weekly for four weeks, then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 4. Social Services Director or Designee will audit elopement books beginning 7/15/19 to ensure they are updated based on new and updated elopement risk assessments weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 5. Employee Relations Director or Designee will audit new hires beginning 7/15/19 to ensure they received elopement procedure training weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 6. Beginning 7/15/19 the DON and/or Designee will audit five elopement risk assessments weekly for four weeks then monthly for two months to ensure any exit seeking behaviors are care planned appropriately. The surveyor reviewed the audit forms. 7. On 7/15/19 results of the audits will be discussed at the Quality Assurance Performance Improvement Committee weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. Noncompliance of F-865 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.	2020-09-01
2391	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-08-30	609	D	1	0	BV6Q11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on policy review, facility investigation review, medical record review, and interview the facility failed to report an allegation of resident to resident abuse for 2 of 3 (Resident #1 and #2) sampled residents reviewed. The findings include: The facility's ABUSE PREVENTION POLICY & PR[NAME]EDURE policy documented, .It is the policy of this facility to take all steps reasonable and necessary to protect the residents from harm at all times, including protection from physical and verbal abuse from other residents .Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions .An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach .The investigation protocol must be implemented and a report given to the appropriate agencies as specified by law and regulations . Medical record review revealed Resident #1 was admitted to the secure Dementia unit at the facility on 9/18/18 with [DIAGNOSES REDACTED]. Review of the quarterly assessment dated [DATE] revealed Resident #1 had a cognitive status score of 8 of 15, indicating moderate impairment and had wandering behaviors. Observations in Resident #1's room on 8/30/19 at 10:10 AM, revealed the resident was ambulatory in her room without assistance, was well groomed and appropriately dressed, had clear speech, and was alert and oriented to person and place. Interview with Resident #1 her room on 8/30/19 at 10:10 AM, when asked if another resident at the facility had hit her, Resident #1 stated, No. Not even the men . Closed medical record review revealed Resident #2 was admitted to the secure Dementia unit in the facility on 7/16/19 with [DIAGNOSES REDACTED]. Review of the 30-day assessment dated [DATE] revealed Resident #2 had a cognitive status score of 0 of 15, indicating severe impairment, had difficulty focusing attention, displayed physical and verbal behavioral symptoms directed toward others, rejected care and wandered. The facility's SUMMARY OF INCIDENT AND INVESTIGATION dated 8/13/19 documented, .CNA (Certified Nursing Assistant) notified nurse on 8/13/19 at approximately 6:30 am that she saw (Named Resident #2) hit (Named Resident #1) on the left forearm 3 times .(Named Resident #2) has a BIM (Brief Interview for Mental Status) of 0 and does not have the ability of mental reasoning to understand what is right or wrong nor does he have the capacity to willfully act in such a manner .After complete investigation, this occurrence was unsubstantiated as abuse. It is determined that (Named Resident #2) did not act deliberately or willfully and that facility staff intervened immediately and appropriately . Review of the facility's investigation revealed Resident #2 was removed from the area immediately and placed on 1:1 observation. The Administrator/Abuse Coordinator was notified of the incident and skin assessment for Resident #1 revealed no bruising and no complaint of pain. Each of the residents' families were notified, the physician was notified and orders were received to transfer Resident #2 to a Psychiatric facility for evaluation and treatment. Telephone interview with CNA #1 on 8/30/19 at 11:55 AM, CNA #1 was asked if she had witnessed Resident #2 hit Resident #1 on 8/13/19. CNA #1 revealed she had heard Resident #1 say a few curse words and saw Resident #2 hit Resident #1 on the left forearm with his fist 3 times. Resident #2 was removed immediately and Resident #1 was assessed and had no complaint of pain or bruising noted. Interview with the Administrator on 8/30/19 at 1:30 PM, in the Administrator Office, the Administrator was asked why the altercation between Resident #1 and Resident #2 on 8/13/19 had not been reported to the State Agency as an abuse allegation. The Administrator confirmed the allegation was not reported to the State Agency and stated she did not report tbecause she determined abuse had not occurred.	2020-09-01
2392	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-10-17	550	D	0	1	PSHT11	Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 5 of 23 (Certified Nursing Assistant (CNA) #1, #4, #6, #7, and #9) facility staff members referred to clothing protectors as bibs, did not use courtesy titles to address residents, used a personal cell phone while assisting a resident with a meal, stood over a resident to assist with a meal, and failed to knock before entering a resident's room. The findings included: 1. The facility's Assisting with Meals policy documented, .Residents shall receive assistance with meals in a manner that meets the individual needs .not standing over residents while assisting them with meals .avoiding the use of labels .bibs . The facility's Quality of Life-Dignity policy revised (MONTH) 2009 documented, .shall be treated with dignity and respect at all times .staff shall knock and request permission before entering residents' room .Staff shall speak respectfully to residents at all times .addressing the resident by his or her name of choice and not 'labeling' .demeaning practices and standards of care that compromise dignity are prohibited .promote dignity . 2. Observations in the 400 Hall Dining Room on 10/14/19 at 12:10 PM, revealed CNA #7 stated to Resident #57, .the bib is cold, isn't it . Observations in the 400 Hall Dining Room on 10/14/19 at 12:17 PM, revealed CNA #6 stated to Resident #57, .that's your food, baby . Observations in Resident #63's room on 10/15/19 at 5:15 PM, revealed CNA #4 looked at her cell phone while she assisted Resident #63 with her meal. Observations in the 200 Hall on 10/15/19 at 5:40 PM, revealed CNA #1 entered Resident #16's room to deliver his meal tray without knocking. Observations in the 200 Hall on 10/15/19 at 5:44 PM, revealed CNA #1 entered Resident #64's room to deliver his meal tray without knocking. CNA #1 then left the room, returned at 5:50 PM, and entered again without knocking. Observations in Resident #243's room on 10/16/19 at 12:40 PM, revealed CNA #9 stood to assist Resident #243 with her meal. Interview with Director of Nursing (DON) on 10/17/19 at 2:41 PM, in the Conference Room, the DON was asked should staff stand to assist a resident with a meal. The DON stated .no . The DON was asked should clothing protectors be referred to as bibs. The DON stated, .I wouldn't think so . Interview with the Director of Nursing (DON) on 10/17/19 at 3:45 PM, in the Conference Room, the DON was asked if he expected staff to knock before entering residents' rooms. The DON stated, Yes.	2020-09-01
2393	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-10-17	565	E	0	1	PSHT11	Based on observation and interview, the facility failed to provide privacy during 1 of 1 meeting with active Resident Council members. The findings include: Observations in the Sunroom on 10/15/19 at 10:00 AM, revealed the Resident Council Meeting location was not completely private. A bi-fold screen was used to block the entrance from hall 500 to the Sunroom but was accessible to anyone on the 500 Hall. During the meeting there were three interruptions: a. A resident on the 500 Hall folded the bi-fold screen, wheeled through the Sunroom to the 200 Hall, and exited through the double doors to the 200 Hall. b. A Certified Nursing Assistant (CNA) from the 500 Hall folded the bi-fold screen, wheeled a resident through the sunroom to the 200 Hall, and exited through the double doors to the 200 Hall. c. The Activity Director entered the room during the meeting and assisted one of the residents to leave the room. Interview with Activity Assistant #2 on 10/17/19 at 9:36 AM in the 400 Hall, Activity Assistant #2 stated, The Resident Council Meeting should never be interrupted.	2020-09-01
2394	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-10-17	577	D	0	1	PSHT11	Based on policy review, observation, and interview, the facility failed to ensure the survey results were readily accessible for all residents residing in the facility. The facility had a census of 98 residents. The findings include: 1. The facility's undated Resident Rights policy documented, .results of the most recent survey of the Center conducted by Federal or State surveyors and any plan of correction in effect to the Center. The Center must make the results available for examination in a place readily accessible to residents . 2. Observations in the Lobby on 10/14/19 at 9:05 AM and 10/15/19 at 11:42 AM, revealed a white binder labeled .Survey Results The results from surveys on 6/10/19, 7/2/19, and 8/30/19 were not available for the residents to review. Interview with the Administrator on 10/16/19 at 4:46 PM, in the Lobby, the Administrator was asked if the survey results were in the survey book from the surveys conducted (June, July, and Sept of 2019). The Administrator stated, .no they are not in there . The Administrator was asked if the survey results should be in the book available for residents to review. The Administrator stated, .yes .	2020-09-01
2395	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-10-17	658	D	0	1	PSHT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, 1 of 2 nurses (Licensed Practical Nurse (LPN) # 4) failed to follow facility policy for administration of medications through a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted into the stomach for nutrition and medication) when medications were pushed through the enteral tube and not allowed to flow per gravity. The findings included: The facilities Administering Medications through an Enteral Tube policy revised (MONTH) (YEAR) documented, .Administer medication by gravity flow . Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Thera liquid give 10 ml (milliliter) .peg .once a day .[MEDICATION NAME] formula capsule .once daily . The physician's orders [REDACTED].[MEDICATION NAME] 0.5 mg tablet per peg . The physician's orders [REDACTED].[MEDICATION NAME] 125 mg (milligram)/5 ml susp (suspension) give 7 ml .PEG 2 TIMES DAILY @ (at) 6 AM & (and) 6 pm . Observations in Resident #35's room on 10/15/19 at 5:09 PM, revealed LPN #4 poured 60 ml of water into Resident #35's PEG and pushed the water through the tube with the plunger. LPN #4 then administered the medications with water and pushed each medication through the tube with the plunger. LPN #4 poured 60 mL of water into the PEG tube and pushed the water through the tube with the plunger. LPN #4 did not allow the medications to flow by gravity, in accordance with the facility's policy. Interview with the Director of Nursing (DON) on 10/17/19 at 7:15 PM, in the Conference Room, the DON was asked should medications be pushed through a PEG tube. The DON stated, .no .should be by gravity .	2020-09-01
2396	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-10-17	684	D	0	1	PSHT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to follow the physician's orders for wound care treatments for 1 of 4 (Resident #70) sampled residents reviewed for wound care. The findings include: Medical record review revealed Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #70 required staff assistance for all activities of daily living, and had Moisture Associated Skin Damage (MASD). The care plan dated 2/25/19 documented, .at risk for skin breakdown r/t (related to) decreased mobility, incontinence .Intervention .Treatments as directed . The Physician's Orders dated 10/7/19 documented, .Start Date .10/03/19 .RLE (Right Lower Extremity) AND LLE (Left Lower Extremity) EXCORIATION .CLEAN C (with) NS (Normal Saline), APPLY SSD (Silver [MEDICATION NAME])/[MEDICATION NAME]/[MEDICATION NAME]/ZINC TRIPLE CREAM EQUAL MIXTURE TO AFFECTED AREAS DAILY ET (and) PRN (as needed) X (times) 14 DAYS, THEN RE-EVALUATE . The Wound Assessment Report dated 10/15/19 documented, .MASD .apt (appointment) (with) .wound clinic on 10/15/19 .N.O. (new order) Cont (Continue) to apply SSD/[MEDICATION NAME]/[MEDICATION NAME]/zinc combined triple cream equal parts to affected areas daily . Observations in Resident #70's room on 10/16/19 at 10:55 AM, revealed Licensed Practical Nurse (LPN) #1 performed wound care to raised reddened areas to Resident #70's bilateral posterior upper thighs. LPN #1 wiped the wound with Aloe disposable wipes, and then applied SSD 1 percent (%) cream to the area. Interview with LPN #1 on 10/17/19 at 6:51 PM, in the 500 Hall, LPN #1 confirmed she applied SSD 1% cream to Resident #70's MASD wounds. LPN #1 was asked if the treatment was administered as ordered. LPN #1 stated, .This is what they sent from (Named Pharmacy) . Interview with the Director of Nursing (DON) on 10/17/19 at 6:54 PM, in the 500 Hall, the DON was asked if the SSD 1% cream was the treatment that was ordered. The DON stated, No.	2020-09-01
2397	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-10-17	725	D	0	1	PSHT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the facility staffing schedules and interview, it was determined the facility failed to provide sufficient staffing to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility had a census of 98 residents. The findings include: 1. Review of the quarterly MDS dated [DATE] revealed Resident #31 had a BIMS score of 15, which indicated no cognitive impairment. Interview with Resident #31 on 10/14/19 at 3:07 PM, in Resident #31's room, Resident #31 was asked about staffing at the facility. Resident #31 stated, Not at night time especially. They say it's just 1 or 2 (staff members) at night. Resident #31 was asked if he had to wait a long time for someone to help him if he called for help. Resident #31 stated, .takes an hour or 2 and sometimes 3 or 4, takes a long time . Even sometimes in the daytime they don't come as quick as they should. 2. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Interview with Resident #29 on 10/14/19 at 3:58 PM, in Resident #29's room, Resident #29 was asked about staffing at the facility. Resident #29 stated, Sometimes at night it's pretty bad, especially at bedtime .have to wait at least 30 minutes before they can go to bed .sometimes at night it's way more than 30 minutes . 3. Review of the admission MDS dated [DATE] revealed Resident #143 had a BIMS score of 15, which indicated no cognitive impairment. Interview with Resident #143 on 10/15/19 at 8:09 AM, in Resident #143's room, Resident #143 was asked about staffing at the facility. Resident #143 stated, A lot of times at night we only have 1 aide for 30-something patients .they (call lights) might go off 30 minutes to an hour before they're answered. 4. During the Resident Council Group meeting, which consisted of 12 alert and oriented residents, the Resident Council Group expressed staffing concerns, which included not enough help at night or on weekends, and 1 staff member works with 30 beds/residents. 5. Review of the Certified Nursing Aide (CNA) schedule revealed there were 3 CNAs scheduled for the night shift (6:45 PM - 7:00 AM) on Sunday 10/13/19. The facility had a census of 99 residents as of midnight 10/14/19. Review of the CNA schedule revealed there was 1 CNA scheduled for 6:45 PM - 11:00 PM, and 3 CNAs scheduled for 6:45 PM - 7:00 AM for the night shift on Monday, 10/14/19. The facility had a census of 99 residents. Review of the CNA schedule revealed there were 4 CNAs scheduled for 6:45 PM - 7:00 AM for the night shift on Tuesday, 10/16/19. The facility had a census of 96. 6. Interview with CNA #2 on 10/15/19 at 8:55 PM, in the Sunroom, CNA #2 was asked if she felt the facility had enough staff for her to get all of her assignments completed. CNA #2 stated, .not enough time to complete everything .way too many residents to care for . CNA #2 was asked how many residents she was assigned tonight. CNA #2 stated, Twenty-five .responsible for 32 at most . Interview with CNA #5 on 10/15/19 at 8:18 PM, in the Secured Unit Lobby, CNA #5 was asked if she felt there was enough staff. CNA #5 stated, No. CNA #5 was asked how many residents she was assigned. CNA #5 stated, .last night .I had 27 on my own .I need to spend more time with the residents . Interview with Licensed Practical Nurse (LPN) #4 on 10/16/19 at 10:55 AM, in the 100 Hall, LPN #4 was asked if she was off after today. LPN #4 stated, No I have to work 12 hour shifts until Saturday (10/19/19) .a nurse walked out .	2020-09-01
2398	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-10-17	757	D	0	1	PSHT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the PHYSICIANS' DESK REFERENCE 69th EDITION, medical record review, observation, and interview, the facility failed to ensure medications administered were appropriately monitored for adverse effects for 1 of 6 (Resident #16) sampled residents reviewed for unnecessary medications. The findings include: 1. The PHYSICIANS' DESK REFERENCE 69th EDITION (YEAR) documented, .[MEDICATION NAME] ([MEDICAL CONDITION] hormone replacement medication) .INDICATIONS AND USAGE .[MEDICAL CONDITION] .Pituitary TSH ([MEDICAL CONDITION] Stimulating Hormone) Suppression .PRECAUTIONS .has a narrow therapeutic index .Regardless of the indication for use, careful dosage titration is necessary to avoid the consequence of over- or under-treatment .These consequences include .effects on .cardiovascular function, bone metabolism .cognitive function, emotional state, gastrointestinal function, and on glucose and lipid metabolism .The adequacy of therapy is determined by periodic assessment of appropriate labortory tests .frequency of TSH monitoring during [MEDICATION NAME] dose titration .is generally recommended at 6-8 week intervals until normalization .When the optimum replacement dose has been attained .It is recommended .a serum TSH measurement be performed at least annually . 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Unspecified Sequelae of Other [MEDICAL CONDITION] Disease. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #16 had severe cognitive impairment and required supervision for all activities of daily living. A hospital discharge summary report dated 3/21/18 documented, .TSH ([MEDICAL CONDITION] Stimulating Hormone) .2/28/2018 .Result .6.44 .H (High) .Reference Range .0.45 - 5.0 .ulU/ml (micro-international units per milliliter) . The physician's orders [REDACTED].Start Date .6/30/18 .[MEDICATION NAME] 0.025 MG (milligrams) TABLET by mouth @ (at) 6am (6:00 AM) daily . The facility was unable to provide documentation that any laboratory testing for [MEDICAL CONDITION] function had been done since the abnormal result was obtained 2/28/18. Observations in Resident #16's room on 10/15/19 at 5:06 PM and 8:45 PM, 10/16/19 at 10:25 AM and 12:11 PM, and on 10/17/19 at 2:32 PM and 6:39 PM, revealed Resident #16 lying in bed with his eyes closed. Interview with the Director of Nursing (DON) on 10/17/19 at 9:01 PM, in the Conference Room, the DON was asked if TSH levels should be monitored for residents taking [MEDICATION NAME]. The DON confirmed these levels should be monitored.	2020-09-01
2399	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-10-17	759	D	0	1	PSHT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, review of the JoVE Science Education Database Nursing Skills. Preparing and Administering Intramuscular Injections, medical record review, observation, and interview, the facility failed to ensure 2 of 8 (Licensed Practical Nurse (LPN) #2 and #3) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 29 opportunities, resulting in an error rate of 6.89%. The findings included: 1. The JoVE Science Education Database. Nursing Skills Preparing and Administering Intramuscular Injections documented, .The deltoid site (upper arm) .immunizations .maximum volume should never exceed 2 mL (milliliters) . The facilty's Administering Medications policy revised (MONTH) 2019 documented, .Medications are administered in a safe and timely manner, and as prescribed .The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions .Medications are administered in accordance with prescriber orders . 2. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] 120 mg (milligram) IM (intramuscular) q (every) 12 hrs (hours) x (for) 14 days . Observations in Resident #18's room on 10/16/19 at 9:15 AM, revealed LPN #2 injected 3 ml of [MEDICATION NAME] into Resident #18's left upper arm (deltoid site). Interview with the Director of Nursing (DON) on 10/17/19 at 8:23 PM, in the Conference Room, the DON was asked is it acceptable to give 3 ml of medication Intramuscular (IM) in the upper arm. The DON stated, .no . Failure of LPN #2 to administer an IM injection of [MEDICATION NAME] of less than 2 ml into the deltoid site resulted in medication error #1. 3. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Humalog .152-200=3 units . Observations in Resident #34's room on 10/16/19 at 4:08 PM, revealed LPN #3 performed a blood glucose level check with a result of 153. Interview with LPN #3 on 10/16/19 at 4:10 PM, at the 400 Hall Nurses' Station, LPN # 3 stated, .doesn't get any insulin . Interview with the DON on 10/16/19 at 8:23 PM, in the Conference Room, the DON was asked how much insulin should Resident #34 receive for a blood glucose of 153. The DON stated, .3 units . The DON confirmed insulin should be administered as ordered. Interview with the Medical Director on 10/17/19 at 3:52 PM, in the Conference Room, the Medical Director was asked if he expected his medication orders to be followed. The Medical Director stated, .Yes ma'am, I expect all my orders to get carried out, they're not just suggestions . Failure of LPN #3 to administer insulin as prescribed resulted in medication error #2.	2020-09-01
2400	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-10-17	760	D	0	1	PSHT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the (YEAR) Boehringer [MEDICATION NAME] Pharmaceuticals, Inc. manufacturer's information, policy review, medical record review, and interview, the facility failed to ensure medications were administered free from significant medication errors for 1 of 24 (Resident #70) sampled residents. The findings include: 1. The (YEAR) Boehringer [MEDICATION NAME] Pharmaceuticals, Inc. manufacturer's information documented, .Take [MEDICATION NAME] once a day . 2. The facility's Medication and Treatment Orders policy with a revision date of 7/2016, documented, .Orders for medications must include .Dosage and frequency of administration .Orders not specifying the number of doses, or duration of medication, shall be subject to automatic stop orders . 3. Medical record review revealed Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 2/25/19 documented, .insulin dependent diabetic .at risk for hypo/[MEDICAL CONDITION] and complications of the disease .Intervention .Medications .as directed per MD (Medical Doctor) .orders . The Physician admission orders [REDACTED].[MEDICATION NAME]-5mg (milligrams)-take 1 tab (tablet) po (by mouth) before meals . The Telephone physician's orders [REDACTED].Order Clarification .[MEDICATION NAME] 5mg po (by mouth) QD (every day) . Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. The (MONTH) 2019 Monthly Consultant Pharmacist Report documented, .Please note the following medication(s) are dosed above the usual geriatric dosage .[MEDICATION NAME] 5mg tid (three times daily) .Recommendation .[MEDICATION NAME] 5mg daily . Telephone interview with the Pharmacist on 10/17/19 at 8:52 AM, the Pharmacist was asked if there had been a problem with Resident #70's diabetic medication, [MEDICATION NAME]. The Pharmacist stated, Yes .There's no way they are supposed to be given three times a day .it was supposed to be given once a day. It was some kind of mistake .She actually went without her meds a few days .It was 9/14 (9/14/19) by the time we got it straightened out . The Pharmacist confirmed Resident #70 ran out of [MEDICATION NAME] before it could be refilled again because it was administered three times daily instead of once daily. Interview with Licensed Practical Nurse (LPN) #5 on 10/17/19 at 9:33 AM, at the Hall 5 Nurses' Desk, LPN #5 was asked if there had been a problem with Resident #70 getting her [MEDICATION NAME] refilled. LPN #5 stated, Yes .it was scheduled for three times a day .insurance would only pay for one time a day. It was ordered .with meals, so the order was put in for 3 times a day. When she ran out, the insurance wouldn't pay for it to be refilled. LPN #5 was asked if it should have been ordered for only once a day instead of 3. LPN #5 stated, Yes. LPN #5 was asked if there was any documentation of the medication order error. LPN #5 provided a physician's telephone order dated 9/27/19 that documented, .Order Clarification .[MEDICATION NAME] 5mg po QD . Interview with the Director of Nursing (DON) on 10/17/19 at 1:00 PM, in the Conference Room, the DON was asked the facility's process for transcribing orders. The DON stated, We just take the hospital orders they sent to us and write them on a physician's orders [REDACTED]. The DON stated, We would clarify the order. The DON confirmed physician medication orders should include how many times a day the medication was to be administered.	2020-09-01
2401	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-10-17	761	D	0	1	PSHT11	Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored when 1 of 9 (500 Lower Hall Medication Cart) medication storage areas was unlocked and unattended. The findings included: The facility's Storage of Medications policy revised (MONTH) 2019 documented .drugs and biologicals .are stored in locked compartments .unlocked medication carts are not left unattended . Observations in the 500 Hall on 10/15/19 at 8:16 PM, the 500 Lower Hall Medication Cart was left unlocked and unattended. Interview with the Director of Nursing (DON) on 10/17/19 at 2:41 PM, in the Conference Room, the DON was asked if medication carts are to be left unlocked. The DON stated, .no .	2020-09-01
2402	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-10-17	812	D	0	1	PSHT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared and served under sanitary conditions as evidenced by a dirty hand-washing sink in the Kitchen, dishwashing racks stored on the floor in the Kitchen, opened, unlabeled and undated foods stored in the Kitchen and in 1 of 3 (,[DATE] Hall Nourishment Room) nourishment rooms, wet towel on the floor in the Kitchen, a dirty steam table in the Kitchen, raw chicken and frozen foods left sitting at room temperature in the Kitchen, and foods on the floor in the Kitchen. The facility had a census of 98 residents, with 91 of those residents receiving a meal tray from the kitchen. The findings include: 1. The facility's FOOD STORAGE policy with a revision date of [DATE], documented, .Food items should be stored, thawed, and prepared in accordance with good sanitary practice. Any expired or outdated food products should be discarded .Use use-by-dates on all food stored in refrigerators .Remember to cover, label and date .Chicken should be stored on ice to maintain an optimal temperature .Vegetables should be left in cartons, bags, or paper wrapping because it retards spoilage and loss of moisture .milk .should be stored .in refrigeration at 41 (degrees) F (Fahrenheit) or less .All foods should be stored .off the floor .Internal thermometers are to be in the warmest area of the refrigerator or freezer .Record temperatures from the internal thermometers .Employee food and resident food should not be stored together . 2. Observations in the Kitchen on [DATE] beginning at 8:45 AM, revealed the following: a. The hand-washing sink had slimy brownish dirty build-up around the faucet b. Two dish racks on the floor in the dishware washer area. The Dietary Manager (DM) confirmed they were on the floor, and picked them up. c. A milk cooler filled with milk and no thermometer inside. The DM confirmed there were no thermometers in the milk cooler. The DM stated, Milk delivery was today .thermometers may have been taken out in the empty crates . d. Milk cooler with undated, unlabeled plastic container with orange-peach colored substance. The DM stated, It looks like a pureed dessert. e. A thawing single serve container of ice cream. The DM removed the ice cream. f. A wet towel on the floor beside the ice machine. The DM removed the wet towel from the floor and stated, We have been having problems with it .waiting on a part for it. g. A portable steam table empty with stained sides and all wells with crusty black dirty substance in the bottom of the wells. The DM stated, .Thermostat went out on the steam table .using this mobile one until the part for the other one comes in .supposed to be here the 25th ([DATE]) . h. Two large shallow baking pans containing uncovered raw chicken breasts. No dietary staff member was working with the foods. The DM stated, .preparing for lunch today . i. A reach-in cooler with 5 uncovered/unlabeled containers of mandarin oranges and 2 uncovered/unlabeled containers of blueberry crumble dessert. The DM stated, It looks like blueberry crumble leftover from Saturday ([DATE]). j. A reach-in cooler with 2 containers of parfait from the local grocery store dated ,[DATE]. The DM removed the parfaits. k. The main milk cooler full of milk with no thermometer. 3. Observations in the Kitchen on [DATE] at 9:56 AM, revealed the following: a. The hand-washing sink had slimy brownish dirty build-up around the faucet b. A reach-in cooler with an opened bag containing 3 lettuce heads, with lettuce spilling out of the bag The DM removed the bag of lettuce. c. Twelve bags of frozen hushpuppies and 1 bag of frozen french fries beside the 3-compartment sink. No dietary staff member was working with the foods. The DM stated, They are making corn nuggets from those. d. An empty portable steam table with stained sides and all wells with crusty black dirty substance in the bottom of the wells. 4. Observations in the ,[DATE] Hall Nourishment Room on [DATE] at 5:35 PM, revealed the following: a. An unlabeled and undated large Styrofoam cup with a straw in it from a local restaurant half-filled with liquid in the resident refrigerator. The Regional Registered Nurse stated, I'm just going to toss it . b. A sandwich wrapped in a local restaurant paper wrapper on top of the microwave. The Regional Registered Nurse threw it in the trash. c. An uncovered/unlabeled/undated cup half full of ice and clear liquid and an unlabeled half-full bottle of water on the counter beside the microwave. The Regional Registered Nurse threw it in the trash. 5. Observations in the Kitchen on [DATE] at 12:00 PM, revealed the following: a. The hand-washing sink had slimy brownish dirty build-up around the faucet b. A case of crushed pineapple and a case of brown sugar on the floor. The Registered Dietician stated, .We just got a shipment. 6. During the Resident Council Group meeting, which consisted of 12 alert and oriented residents, the Resident Council Group expressed concerns the ice cream was not served cold. 7. Interview with the DM on [DATE] at 8:20 AM, in the Conference Room, the DM was asked how foods should be stored in the refrigerator. The DM stated, Produce needs to be stored in refrigerator usually in the box or we unpack them into or a plastic box with a lid, covered, and dated when they come in .Produce is good for 1 week .leftovers, we cool it down and store it for 3 days in the cooler in plastic bins with lids, labels, and dates. The DM was asked if any foods should be stored uncovered, unlabeled, or undated. The DM stated, No. Everything should be labeled. The DM was asked if foods should be stored in boxes on the floor. The DM stated, No .He brings it in on a dolly .until we get it unpacked and put away, it is going to be on the floor. The DM was asked if the nourishment room refrigerators were managed by the kitchen staff. The DM confirmed they did, and confirmed anything that does not belong to the residents, and anything that was not labeled and dated was not acceptable. The DM was asked how often the steam table and the hand-washing sink were cleaned or wiped down. The DM stated, As often as possible between tasks. The DM confirmed there was no set schedule for cleaning the hand-washing sink or the steam table. The DM was asked if there should always be thermometers in the refrigerators and freezers. The DM stated, Yes. The DM was asked about the 2 pans of raw chicken on the stove top. The DM stated, It was marinating in herbs .She had just filled one of the sheet pans . The DM was asked if it should have been covered. The DM stated, I would say yes.	2020-09-01
2403	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-10-17	842	D	0	1	PSHT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the Resident Assessment Instrument (RAI) Manual, policy review, medical record review, observation, and interview, the facility failed to ensure accurate documentation related to pressure ulcers for 1 of 4 (Resident #31) sampled residents reviewed for pressure ulcers and medication administration related to insulin and intravenous (IV) antibiotics for 2 of 6 (Resident #59 and #61) sampled residents reviewed for unnecessary medications. The findings include: 1. Review of the RAI Manual, (YEAR) Minimum Data Set (MDS) 3.0 Updates, revealed that when a resident who is admitted to the nursing home without a pressure ulcer develops a pressure ulcer in the nursing home, is admitted to the hospital for acute condition changes and then readmitted to the nursing home with the same pressure ulcer, that pressure ulcer is not considered present on admission but is a facility acquired pressure ulcer. Medical record review revealed Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A weekly Wound Assessment Report dated 3/27/19 documented, .Wound Type .Pressure Ulcer .Location .Coccyx .Date Wound Identified .8/29/2017 .Present upon admission .No .Stage 4 . A weekly Wound Assessment Report dated 4/2/19 documented, .Wound Type .Pressure Ulcer .Location .Coccyx .Date wound identified .4/2/19 .Present upon admission .Yes .Assessment Occasion .Re-assessment .Resident out of the facility From Date .3/28/2019 .Thru Date .4/2/2019 . All weekly Wound Assessment Reports from 4/2/19 through 10/15/19 documented, .Date wound identified .4/2/2019 .Present upon admission .Yes . Observations in Resident #31's room on 10/16/19 at 10:08 AM, revealed wound care was performed on Resident #31's Stage 4 coccyx pressure ulcer. Interview with Licensed Practical Nurse (LPN) #1 on 10/16/19 at 3:10 PM, in the 400 Hall Dining Area, LPN #1 was asked if Resident #31 had a stage 4 coccyx pressure ulcer when he went out to the hospital on [DATE]. LPN #1 stated, He had it when he went out .was a Stage 4 .it is the same wound .it's the only wound he's had on his bottom . Interview with the Regional Director of Clinical Services on 10/16/19 at 6:02 PM, in the Front Lobby, the Regional Director of Clinical Services was asked should Resident #31's weekly wound assessment document that his pressure ulcer was present on admission when it was a facility acquired pressure ulcer. The Regional Director of Clinical Services stated, .Coming back from the hospital, if it was a facility acquired wound, the record should always reflect that it is a facility acquired wound . 2. Review of the facility's Administering Medications policy revised (MONTH) 2019 documented .medications are administered in accordance with prescriber orders, including any required time frame . Medical record review revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED].#59 had scheduled accuchecks before meals and at bedtime with the following Humalog Sliding Scale Insulin: HUMALOG 100 UNIT/(per) ML (milliliters) .SLIDING SCALE .0-199=0U (units); 200-250=2U; 251-300=4U; 301-350=6U; 351-400=8U; 401 >=10U AND RECHECK IN 30 MINUTES . Review of the Medication Administration Record [REDACTED] a. 8/19/19 at 6:30 AM the blood glucose was 110 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. b. 8/19/19 at 5:30 PM the blood glucose was 127 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. c. 8/22/19 at 6:30 AM the blood glucose was 119 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. d. 8/27/19 at 6:30 AM the blood glucose was 113 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. e. 9/1/19 at 6:30 AM the blood glucose was 114 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. f. 9/5/19 at 6:30 AM the blood glucose was 118 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. g. 9/14/19 at 6:30 AM the blood glucose was 142 and 1 unit of insulin was documented as administered. 0 units of insulin was ordered to be administered. Review of the (MONTH) 2019 Medication Regimen Review by the Pharmacist for Resident #59 revealed the resident .appears to have been given a dose of SSI (sliding scale insulin) (1 unit) at 6:30 on (MONTH) 1st, 5th, and 14th. Blood sugars were 114, 118, and 142, respectively. Per the active order, the use of SSI starts at a blood sugar of 200 (2 units). Erroneous administration of SSI could lead to severe [DIAGNOSES REDACTED]. Please ensure that the nurses double check sliding scale instructions prior to administration . Interview with LPN #5 on 10/17/19 at 9:20 AM, in the 500 Hall, LPN #5 confirmed Resident #59's blood glucose level was never high enough to receive insulin. LPN #5 reviewed Resident #59's blood glucose record for (MONTH) and (MONTH) 2019 and confirmed Resident #59 did receive insulin three times each month. She also confirmed Resident #59 should never have received insulin for the blood glucose level documented. Interview with the Director of Nursing (DON) on 10/17/19 at 2:25 PM, in the Conference Room, the DON confirmed no insulin should have been administered with the blood glucose levels documented. Interview with the Medical Director on 10/17/19 at 3:44 PM, in the Conference Room, the Medical Director stated, I do not understand why this happened according to the sliding scale orders. Interview with the DON on 10/17/19 at 5:25 PM, in the Conference Room, the DON stated that both nurses responsible for the inaccurate documentation were new graduate nurses and it was a computer medication education issue. 3. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician's admission orders [REDACTED].[MEDICATION NAME] .80mg (milligrams) / (per) 2ml (milliliters) .420mg/NS (Normal Saline) .100ml .220ml/HR (hour) .q (every) 24 (hours) .D/C (discontinue) 10-19-19 . The (MONTH) 2019 Medication Administration Record [REDACTED]. [MEDICATION NAME] .was not administered .Resident not available . The NURSE notes dated 10/14/19 documented, .IV (Intravenous) antibiotics given at 1015 (10:15 AM) . Observations in Resident #61's room on 10/14/19 at 10:56 AM, revealed Resident #61 sitting in a wheelchair at bedside. [MEDICATION NAME] was infusing IV per pump at 220 ml/hr. Interview with the DON on 10/17/19 at 5:26 PM, in the Conference Room, the DON was asked about the documentation on the MAR indicated [REDACTED]. The DON stated, I think the problem with the documentation might be the LPNs are signing it off, and the RNs (Registered Nurses) are actually the ones giving it .	2020-09-01
2404	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2019-10-17	880	D	0	1	PSHT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when isolation precautions were not followed for 1 of 2 (Resident #49) sampled residents reviewed and facility staff failed to protect resident's personal clothing from environmental contamination. The findings include: 1. The facility's Isolation - Categories of Transmission-Based Precautions policy revised (MONTH) (YEAR) revealed .when a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution .The signage informs the staff of the type of CDC (The Centers for Disease Control) (CDC) precaution(s), instructions for use of PPE (personal protective equipment), and/or instructions to see a nurse before entering the room . Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Pt (patient) to be in contact isolation r/t (related to)[MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) in wound . Observations in the 500 Hall on 10/14/19 at 8:30 AM, revealed no isolation signs on Resident #49's door. Resident #49 had a roommate who was not in isolation. Observations in the 500 Hall on 10/14/19 at 9:00 AM, revealed Licensed Practical Nurse (LPN) #7 donned gloves to enter Resident #49's room. LPN #7 confirmed that she wore gloves only because his wounds were contained and he was not contagious. Observations on 10/15/19 in the 500 hall revealed the following: a. Certified Nursing Assistant (CNA) #3 entered Resident #49's room at 8:00 AM to deliver the breakfast tray. CNA #3 did not wear gloves or any Personal Protective Equipment (PPE) when she entered the room. b. CNA #4 entered Resident #49's room at 5:45 PM to deliver the supper tray. CNA #4 did not wear gloves or any PPE when she entered the room. Interview with CNA #3 and CNA #4 on 10/15/19 at 6:30 PM, in the 500 Hall, CNA #3 and CNA #4 stated the wounds were contained and PPE was not required. Interview with LPN #1 on 10/17/19 at 9:30 AM, LPN #1 confirmed staff should don gowns, gloves, and foot covers before entering Resident #49's room. LPN #1 was asked should Resident #49 and Resident #62 share a room. LPN #1 stated it was safe for Resident #49 and #62 to be in the same room because Resident #49 had a [MEDICAL CONDITION] and a suprapubic catheter and they did not share a bathroom. LPN #1 confirmed that Resident #49's [MEDICAL CONDITION] and catheter bags were emptied into the commode that Resident #62 used. 2. Review of the facility's Laundry and Linen policy revised (MONTH) 2014 documented, .The purpose of this procedure is to provide a process for the safe and aseptic handling .of linen .clean linen will remain hygienically clean (free of pathogens (germs)) . Interview with Laundry Assistant #1 on 10/17/19 at 9:00 AM, in the 500 Hall, Laundry Assistant #1 revealed three of four dryers were not working on Tuesday 10/15/19 so wet laundry was taken to the community laundromat to dry the resident clothes. Laundry Assistant #1 confirmed she did not disinfect the dryers prior to placing the resident's personal clothing in the dryers.	2020-09-01
2405	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2018-12-12	584	D	0	1	38WC11	Based on policy review, observation, and interview the facility failed to maintain a sanitary environment in 1 of 50 (Resident #21, 30, 48, and 66's shared bathroom) resident bathrooms. The findings include: 1. The facility's Cleaning and Disinfecting residents' Rooms policy with a revision date of 8/13 documented, .Housekeeping surfaces .will be cleaned on a regular basis .and when these surfaces are visibly soiled . 2. Observations in Resident #21, 30, 48, and 66's shared bathroom on 12/10/18 at 11:12 AM revealed bowel movement in the toilet, a brown substance smeared on the toilet seat, and crumpled used paper towels lying on top of the toilet tissue dispenser beside the toilet. Observations in Resident #21, 30, 48, and 66's shared bathroom on 12/10/18 at 2:39 PM and 4:35 PM revealed a brown substance smeared on the toilet seat and on top of the toilet tissue holder beside the toilet. Interview with Certified Nursing Assistant (CNA) #1 on 12/10/18 at 4:38 PM in Resident #21, 30, 48, and 66's shared bathroom, CNA #1 was asked who cleaned the bathrooms. CNA confirmed it was housekeeping staff. CNA #1 was asked how often they are cleaned. CNA #1 stated, They are here from 6 in the morning until .maybe 2. I don't see them after I come back from lunch. CNA #1 was asked if the smeared brown substance on the toilet seat and on the toilet tissue dispenser was acceptable. CNA #1 stated, No, not at all. CNA #1 was asked if the residents use that bathroom. CNA #1 stated, Yes, (Resident #30) does. Interview with the Director of Nursing (DON) on 12/12/18 at 2:27 PM in the conference room , the DON was asked how often he expected staff to make rounds in resident rooms and bathrooms. The DON stated, At least every 2 hours and PRN (as needed) . The DON was asked if it was acceptable for a resident bathroom to have unflushed bowel movement in the toilet, a brown substance smeared on the toilet seat and on the toilet paper dispenser in a resident's bathroom. The DON stated, No ma'am.	2020-09-01
2406	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2018-12-12	604	D	0	1	38WC11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview the facility failed to ensure residents were free from physical restraints for 1 of 1 (Residents #77) resident reviewed for restraints. The findings include: The Physical Restraint Application policy dated (MONTH) 2010 documented, .Physical restraints are defined by Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily .The resident must be physically and cognitively able to self-release devices such as .seat belts with Velcro, or easy snap seat belts. If a resident cannot mentally and physically self-release, then the device is considered a restraint . Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed severe cognitive impairment and no use of physical restraints. The Care Plan dated 11/8/18 documented, .May use seat belt on wheelchair for safety. Check every 30 min (minutes) and release every 2 hours . The physician orders [REDACTED].MAY USE SEAT BELT ON W/C (wheelchair) TO PREVENT UNASSISTED TRANSFER D/T (due to) Dementia .CHECK EVERY 30 MINUTES AND RELEASE Q (every) 2 HRS (hours) . Observations in the 400 hall dayroom on 12/10/18 at 9:40 AM, 11:04 AM, and 5:22 PM, and on12/12/18 at 8:40 AM revealed Resident #77 seated in a wheelchair on a Pommel cushion with a seat belt fastened across her lap. Observations in the 400 hall dayroom on 12/12/18 at 10:51 AM revealed Resident #77 seated in her wheelchair on a Pommel cushion. Interview with the Director of Nursing (DON) in the conference room on 12/10/18 at 1:13 PM, the DON was asked about the seat belt. The DON stated, .She has had it for at least 3 years . Interview with Certified Nursing Assistant (CNA) #2 on 12/12/18 at 8:47 AM on the 400 hall, CNA #2 was asked when the seat belt was removed from Resident #77. CNA #2 stated, .At transfer and at relaxed points. It stays on her . CNA #2 was asked if Resident #77 was on a schedule to get the seat belt removed. CNA #2 stated, No . Interview with Therapy Program Manager on 12/12/18 at 9:04 AM in the Therapy office, the Therapy Program Manager was asked if she Resident #77 had been evaluated for the need of the seat belt. The Therapy Program Manager stated, We have not evaluated her . Interview with Licensed Practical Nurse (LPN) #4 on 12/12/18 at 9:21 AM on the 400 hall, LPN #4 was asked if Resident #77 could release the seat belt on her own. LPN #4 stated, No . Interview with the DON on 12/12/18 at 11:36 AM in the conference room, the DON was asked if Resident #77 had a seat belt and Pommel restraint cushion. The DON confirmed she did. The DON was asked if the seat belt or the Pommel cushion were assessed as restraints before they were initiated. The DON stated, .I'm unable to give you a restraint assessment . Interview with the DON and the Administrator on 12/12/18 at 5:17 PM in the conference room, the DON was asked how he determined the seat belt and the Pommel cushion were not restraints if there were no restraint assessments conducted. The DON stated, I use nursing judgment . The DON was asked if on-going evaluations/assessments were done for the physical restraints. The DON stated, I will look for my assessment. The facility was unable to provide documentation that restraint assessments were conducted prior to initiation of the seat belt and Pommel cushion and was unable to provide documentation for ongoing quarterly restraint assessments for the seat belt and Pommel cushion.	2020-09-01
2407	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2018-12-12	623	D	0	1	38WC11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review and interview, the facility failed to notify the Ombudsman of an emergency transfer for 1 of 4 (Resident #65) sampled residents reviewed for hospitalization . The findings include: 1. The facility's Transfer or Discharge Notice policy dated (MONTH) (YEAR) documented, a copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman . 2. Medical record review revealed Resident #65 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].send to ER (emergency room ) . Review of the facility's Emergency Transfers from Facility form for (MONTH) (YEAR) revealed Resident #65 was not on the list. The facility was unable to provide documentation the Ombudsman had been notified when Resident #65 was transferred to the hospital on [DATE]. Interview with the Director of Nursing (DON) on 12/12/18 at 9:38 AM in the conference room, the DON confirmed Resident #65 was not on the (MONTH) Emergency Transfer form.	2020-09-01
2408	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2018-12-12	641	D	0	1	38WC11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to accurately assess residents for physical restraints for 1 of 18 (Resident #77) sampled residents reviewed. The findings include: Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment, was totally dependent on staff for all activities of daily living (ADLs), and no use of physical restraints. The physician orders [REDACTED].MAY USE SEAT BELT ON W/C (wheelchair) TO PREVENT UNASSISTED TRANSFER D/T (due to) Dementia .CHECK EVERY 30 MINUTES AND RELEASE Q (every) 2 HRS (hours) . Observations in the 400 hall dayroom on 12/10/18 at 9:40 AM, 11:04 AM, and 5:22 PM and on 12/12/18 at 8:40 AM revealed Resident #77 seated in a wheelchair on a Pommel cushion with a seat belt fastened across her lap. Observations in the 400 hall dayroom on 12/12/18 at 10:51 AM revealed Resident #77 seated in a wheelchair on a Pommel cushion. Interview with the Director of Nursing (DON) on 12/12/18 2:47 PM in the conference room, the DON was asked whether the seat belt and Pommel cushion should be coded as restraints on the MDS assessments. The DON stated, It is not coded as a restraint, because it is not a restraint. The facility was unable to provide documentation that a restraint assessment was performed to determine if the seat belt and pommel cushion were restraints.	2020-09-01
2409	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2018-12-12	656	D	0	1	38WC11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview the facility failed to follow care plan interventions related to pain assessments for 2 of 18 (Resident #40, and #64) sampled residents. The findings include: 1. The facility's Using the Care Plan policy documented, .The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident .6. Documentation must be consistent with the resident's care plan . 2. Medical record review revealed Resident #40 was admitted to the facility under hospice care on 10/22/18 with the [DIAGNOSES REDACTED]. The Care Plan dated 11/3/18 documented, .Evaluate pain at least Q (every) shift and PRN (as needed). Administer pain medication as needed and evaluate effectiveness. Interview with Licensed Practical Nurse (LPN) #1 on 12/12/18 at 11:15 AM at the 100 hall nurse station, LPN #1 was asked if the Pain Assessments were completed for Resident #40. LPN #1 stated, We don't have them. Interview with the Director of Nursing (DON) on 12/12/18 at 2:45 PM in the conference room, the DON confirmed the pain assessments were not documented on the Medication Administration Record. The DON was asked if the pain assessments were documented for Resident #40 and if the care plan was being followed for Resident #40. The DON stated, No. 3. Medical record review revealed Resident #64 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Care Plan dated 11/20/18 documented, .At risk for alteration in comfort r/t (related to) [MEDICAL CONDITION] Arthritis, RLS (restless leg syndrome)/Leg cramps. Muscle spasms .Assess and establish level of pain using numeric scale .Asses (assess) pain every shift and document on pain assessment flow sheet located on MAR (Medication Administration Record) . Interview with LPN #2 on 12/11/18 at 2:10 PM at the 500 hall nurses station, LPN #2 was asked if she performed pain assessments on her shift for each resident. LPN #2 stated, .If they are not on a pain medication I will not ask . Interview with the DON on 12/12/18 at 2:12 PM in the dining room, the DON was asked if pain assessments were performed for every resident on each shift. The DON stated, .We adopted a new electronic medication record in (MONTH) of this year, and that could explain why it is not on the MAR. The DON was asked if pain assessments should be documented on the MARs. The DON stated, Yes. The Don was asked if the care plan was being followed. The DON stated, No .	2020-09-01
2410	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2018-12-12	697	D	0	1	38WC11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to ensure pain assessments were completed according to the facility policy for 2 of 7 (Resident #40 and Resident#64) sampled residents reviewed for pain. The findings include: 1. The facility's Pain Assessment and Management policy with a revised date of (MONTH) (YEAR) documented, .The purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain .Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level .Document the resident's reported level of pain .Upon completion of the pain assessment, the person shall record the information obtained from the assessment in the resident's medical record . 2. Medical record review revealed Resident #40 was admitted to the facility under hospice care on 10/22/18 with the [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented Resident #40 was severely cognitively impaired, required extensive to total staff assistance for activities of daily living, and received scheduled pain medication or was offered as needed (PRN) pain medications. The Care Plan dated 11/3/18 documented, .at risk for alteration in comfort r/t (related to) [MEDICAL CONDITION] and End Stage disease process .Resident will be kept comfortable while on hospice .Evaluate pain at least Q (every) shift and PRN. Administer pain medication as needed and evaluate effectiveness. The physician's orders [REDACTED].[MEDICATION NAME] HCL 50 MG (milligrams) TABLET GIVE 1/2 TABLET 25 MG BY MOUTH AS NEEDED EVERY 8 HOURS FOR PAIN .10/29/18 .[MEDICATION NAME] 300 MG CAPSULE BY MOUTH THREE TIMES DAILY . Interview with Licensed Practical Nurse (LPN) #1 on 12/12/18 at 11:15 AM at 100 hall's nurses station, LPN #1 was asked if the Pain Assessments were completed. LPN #1 stated, I couldn't find those pain assessments .We don't have them. Interview with the Director of Nursing (DON) on 12/12/18 at 2:45 PM in the conference room, the DON was asked if the pain assessment documentation was on the medication administration record. The DON stated, No. The DON was asked if the pain assessments were documented for Resident #40. The DON stated, No. There was no documentation on the electronic Medication Administration Record (MAR) that pain assessments were conducted after admission to the facility on [DATE]. 3. Medical record review revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 11/20/18 documented, .At risk for alteration in comfort r/t (related to) [MEDICAL CONDITION] Arthritis, RLS (Restless Leg Syndrome)/Leg cramps. Muscle spasms .Assess and establish level of pain using numeric scale .Asses (assess) pain every shift and document on pain assessment flow sheet located on medication administration record . Review of the (MONTH) and (MONTH) MAR revealed no documentation of pain assessments having been performed. Interview with LPN #2 on 12/11/18 at 2:10 PM at the 500 hall nurses station, LPN #2 was asked if she did pain assessments on her shift for each resident. LPN #2 stated, .If they are not on a pain medication I will not ask . LPN #2 confirmed Resident #64 did not have physician orders [REDACTED]. Interview with the DON on 12/12/18 at 2:12 PM in the dining room, the DON was asked if every resident received a pain assessment on each shift. The DON stated, .it is not on the MAR. The DON was asked if pain assessments should be documented on the MAR. The DON stated, Yes. The facility was unable to provide documentation that the pain assessments were completed for each resident each shift and as needed.	2020-09-01
4152	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2016-11-16	279	D	0	1	HQE411	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, the facility failed to develop a plan of care that identified the resident's dental status for 1 of 2 (Resident #22) sampled residents of the 36 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #22 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment, and dental problems of broken or loosely fitting dentures. Review of the comprehensive care plan dated 8/2/16 revealed no documentation of Resident #22's current dental status or dental needs. Observations in Resident #22's room on 11/15/16 at 7:43 AM, revealed Resident #22 was edentulous. Interview with Resident #22 on 11/14/16 at 12:33 PM, in Resident #22's room, Resident #22 was asked whether he had any problems with his teeth, gums, or dentures. Resident #22 stated, Yes, they broke .they are missing now. Resident #22 was asked whether staff was taking care of these problems satisfactorily. Resident #22 stated, No, I don't know what happened to my teeth . Interview with the Regional Director of Clinical Compliance (RDCC) on 11/16/16 at 10:11 AM, in the MDS office, the RDCC was asked if there was a care plan reflecting Resident #22's dental status. The RDCC stated, Dental triggered .there should have there been one for dental .His lower dentures are broken .the care planning decision is marked yes .there should have been a care plan for dental. The facility was unable to provide a care plan for Resident #22's dental status.	2019-11-01
4153	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2016-11-16	332	D	0	1	HQE411	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation and interview, the facility failed to ensure 1 of 5 (Licensed Practical Nurse (LPN) #1) staff nurses administered medications with a medication error rate of less than 5 Percent (%). A total of 5 medication errors were made out of 25 opportunities, resulting in a medication error rate of 20%. The findings included: The facility's Crushing Medications policy documented, .Crushed medications should be administered with .soft foods to ensure that the resident receives the entire dose ordered . Medical record reviewed revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].MAY CRUSH ALL CRUSHABLE MEDS (medications) MIXED IN PUDDING .[MEDICATION NAME] .0.75(milligrams) .STRESS B WITH ZINC TABLET GIVE 1 .[MEDICATION NAME] ([MEDICATION NAME]) 100 MG (MILLIGRAMS) CAPSULE .[MEDICATION NAME] .7.5 MG TABLET .[MEDICATION NAME] 100 MG 1 (TABLET) . Observations in Resident #5's room on 11/15/16 beginning at 9:26 AM, revealed LPN #1 administered [MEDICATION NAME] 0.75 mg, Stress Formula with Zinc, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 7.5 mg, and [MEDICATION NAME] 100 mg crushed in a cup mixed with pudding. LPN#1 left pill fragments in the cup and on the spoon. Interview with the Director of Nursing (DON) on 11/16/16 at 11:35 AM, in the DON's office, the DON was asked if is it appropriate for any of the crushed medications to be left in the cup or on the spoon after medication administration. The DON stated, No.	2019-11-01
4154	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2016-11-16	371	F	0	1	HQE411	Based on policy review, observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by carbon build-up on pans, the deep fryer, the flat grill, and the oven, and by dietary staff with exposed hair in the kitchen on 2 of 3 (11/14/16 and 11/15/16) days of the survey. The facility had a census of 89, with 86 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's POTS AND PANS - SANITIZING SOLUTION policy documented, .Pots and pans need to be free of black buildup deep scratches and dents . Observations in the kitchen on 11/14/16 at 6:30 AM, and on 11/15/16 at 11:33 AM, revealed carbon build-up and grease on 6 sheet pans. Interview with the Dietary Manager (DM) on 11/15/16 at 11:45 AM, in the kitchen, the DM was asked if it was appropriate to have carbon and grease build-up on sheet pans in the clean area. The DM stated No, it's not acceptable. 2. The facility's DEEP-FAT FRYER policy documented, .Turn off the heating element, drain, rinse with warm vinegar water then rinse thoroughly with clear hot water .wipe the fryer completely dry .Clean the outside of the fry kettle with grease solvent . The facility's OVEN - CONVENTIONAL, GAS policy documented, .remove spills, spillovers, and burned food deposits . The facility's GRILL - GAS policy documented, .Scrape grill to loose burned-on particles .Wash back and side guards with soap and water . Observations in the kitchen on 11/14/16 at 6:30 AM, and on 11/15/16 at 11:33 AM, revealed carbon build-up on the deep fryer, the flat grill, and the oven. Interview with the DM on 11/15/16 at 11:45 AM, in the kitchen, the DM was asked if it was appropriate to have carbon build-up on kitchen equipment. The DM stated, No, it's not acceptable. 3. The facility's PERSONAL HYGIENE policy documented, .Wear .a hair restraint .Hair must be .completely covered . Observations in the kitchen on 11/14/16 and 11/15/16 revealed the following Dietary Staff (DS) with exposed hair: a. 11/14/16 at 6:30 AM, DS #2 with bangs not covered b. 11/14/16 at 3:00 PM, DS #5 with sides and back of hair not covered c. 11/14/16 at 3:01 PM, DS #1 with back of hair not covered d. 11/15/16 at 11:33 AM, DS # 3 with back of hair not covered e. 11/15/16 at 11:33 AM, DM with sides of hair not covered f. 11/15/16 at 3:41 PM, DS #4 with beard not covered Interview with the DM on 11/15/16 at 11:45 AM, in the kitchen, the DM was asked whether it was appropriate to have staff in the kitchen with hair not completely covered. The DM stated, No.	2019-11-01
4155	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2016-11-16	412	D	0	1	HQE411	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, the facility failed to provide dental services to meet the needs of 1 of 2 (Resident #22) sampled residents reviewed of the 36 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #22 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment, and dental problems of broken or loosely fitting dentures. Review of the comprehensive care plan dated 8/2/16 revealed no documentation of Resident #22's current dental status or dental needs. Observations in Resident #22's room on 11/15/16 at 7:43 AM, revealed Resident #22 was edentulous. Interview with Resident #22 on 11/14/16 at 12:33 PM, in Resident #22's room, Resident #22 was asked whether he had any problems with his teeth, gums, or dentures. Resident #22 stated, Yes, they broke .they are missing now. Resident #22 was asked whether staff was taking care of these problems satisfactorily. Resident #22 stated, No, I don't know what happened to my teeth . Interview with the Marketing Director/Interim Social Worker (MDISW) on 11/16/16 at 7:51 AM, on the 300 hallway, the MDISW was asked if she had any information about Resident #22's broken and missing dentures. The MDISW stated, I have not heard of anything . Interview with the MDISW on 11/16/16 at 8:41 AM, in the conference room, the MDISW stated, I checked, and he is not on any (dental) list .MDS did not communicate it over, so that is why he was missed . Interview with the Regional Director of Clinical Compliance (RDCC) on 11/16/16 at 10:11 AM, in the MDS office, the RDCC was asked if there was a care plan reflecting Resident #22's dental status. The RDCC stated, Dental triggered .there should have there been one for dental .His lower dentures are broken .	2019-11-01
4156	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2016-11-16	441	D	0	1	HQE411	Based on observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 2 of 5 (Licensed Practical Nurse (LPN) #1 and #2) staff nurses failed to clean a stethoscope before or after use, and failed to perform proper hand hygiene during medication administration. The findings included: Observations in Resident #5's room on 11/15/16 beginning at 9:26 AM, revealed LPN #1 placed the stethoscope on the resident's skin to check placement of a percutaneous endoscopic gastrostomy (PEG) tube. LPN #1 failed to clean the stethoscope before and after medication administration through Resident #5's PEG tube. Observations in Residents #77's room on 11/15/16 beginning at 10:53 AM, revealed LPN #2 used gloved hands to administer nasal spray medication to Resident #77. LPN #2 then went back to the medication cart in the hall, picked up a pen, opened the Medication Administration Record (MAR) binder, and began writing, all while still wearing the contaminated gloves. Interview with the Director of Nursing (DON) on 11/16/15 at 11:35 AM, in the DON's office, the DON was asked whether she expected staff to clean the stethoscope before and after checking PEG tube placement. The DON stated, Yes. The DON was asked whether it was appropriate to walk out of the room, touch a pen and chart while still wearing gloves that were worn during nasal spray administration. The DON stated, No.	2019-11-01
5673	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2015-09-30	250	E	0	1	DWQY11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, review of a job description, medical record review, and interview, the facility failed to ensure the Social Service Director (SSD) participated, reviewed and updated the plans of care during quarterly interdisciplinary care plan meetings for 13 of 17 (Residents #5, 7, 34, 36, 44, 58, 85, 88, 92, 93, 108, 109 and 118) sampled residents of the 27 residents included in the stage 2 review. The findings included: 1. The facility's Social Services Role and Policies policy documented, .Social services staff will participate as members of the interdisciplinary team (IDT), which reviews and plans the care of the resident . Social services will evaluate how the resident has adapted to the facility and whether there are any current personal needs. Social services will also determine whether there are any psychosocial adjustments or behavior problem . Social services will chart at least every 3 months. This documentation will include progress toward the care plan goals for identified psychosocial problems. Care plan approaches and problems will be re-evaluated at that time to ensure that they are working, and revisions will be done as needed . Duties include the following . 6. Participate as part of the interdisciplinary team in maintaining a plan of care . 2. The facility's SSD job description documented, .Participate in resident care planning by identifying the social and emotional needs of the residents in accordance with the medical assessment . Maintain progress notes for each resident as required by company policy and state and federal regulations, indicating response to the treatment plan and adjustment to facility life . 3. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 2/23/15, 5/14/15 and 8/5/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 4. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 4/20/15 and 7/27/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 5. Medical record review revealed Resident #34 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]., Hypertension, [DIAGNOSES REDACTED], Neuropathy, Edema, Abnormality of Gait, and Diabetes. Review of an IDT Care Plan Review Summary dated 3/10/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 6. Medical record review revealed Resident #36 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 2/23/15 and 8/11/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 7. Medical record review revealed Resident #44 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 3/10/15, 6/4/15, and 8/24/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 8. Medical record review for Resident #58 revealed the resident was admitted to the facility 12/9/09 with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 1/12/15, 4/7/15 and 6/29/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 9. Medical record review revealed Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 3/31/15 and 6/23/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 10. Medical record review revealed Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 4/20/15 and 7/14/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 11. Medical record review revealed Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 4/13/15 and 7/14/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 12. Medical record review revealed Resident #93 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 3/2/15, 5/26/15, and 8/25/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. Interview with the Administrator on 9/29/15 at 2:35 PM, at the 100 Nurses Station, the Administrator stated, As far as I know there are no social notes on Resident #93. The Administrator was asked if that was the normal procedure. The Administrator stated, No, she should have social notes documenting the assessments. 13. Medical record review revealed Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 2/26/15 and 5/17/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 14. Medical record review revealed Resident #109 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 8/4/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 15. Medical record review revealed Resident #118 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of an IDT Care Plan Review Summary dated 8/25/15, revealed no documentation that the SSD participated in the quarterly care planning process to identify the resident's needs and assist in finding options for meeting identified physical and emotional needs of the resident. 16. Interview with the Director of Nursing (DON) on 9/29/15 at 4:45 PM, in the conference room, the DON was asked what she expected from her SSD. The DON stated, I expect her (SSD) to provide a social assessment upon admission, and any needs they are aware of. Interview with SSD on 9/30/15 beginning at 4:43 PM in conference room, the SSD was asked about the missing quarterly social service assessments. The SSD stated, I was under the impression that the MDS (Minimum Data Set) quarterly was the quarterly assessments. The SSD confirmed that she knows about the residents, but just doesn't document it. The SSD was asked about the quarterly care plan summaries that do not contain any social services comments. The SSD stated, Yes, Ma'am, I'm supposed to put something in there. On some of these (care planning summaries), no, I do not (document). The SSD was asked about the care plan review summaries without her signature, and if that indicated she did not attend those particular meetings (IDT care plan review meetings). The SSD stated, No, not at all. It just means I didn't get to the computer to put it (social updates) in. The SSD confirmed that she does quarterly assessments in conjunction with the quarterly MDS assessments, and notes would be on the care plan review summaries. The SSD was asked if she had received a copy of her job description. The SSD stated, I might have when I first started. I just don't remember it. Interview with Administrator on 9/30/15 beginning at 4:43 PM in conference room, the Administrator was asked if she had ever gone over the social service regulations with the SSD. The Administrator stated, No ma'am. I'm being honest. When I came here, she (SSD) was already here. She had been here a year before I got here, and I just assumed she knew.	2019-01-01
7335	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2014-08-20	371	D	0	1	ECQ511	Based on policy review, review of the kitchen cleaning schedule, observation, and interview, it was determined the facility failed to maintain kitchen sanitation as evidenced by 3 individual butter containers and dust on the floor under the fryer; splattered grease on the floor, sides and back splash of the fryer and a dark brown grease inside the fryer on 2 of 3 (8/18/14 and 8/19/14) days of the survey. The findings included: 1. Review of the facility's Dietary Department Guidelines policy documented, .All food preparation equipment, dishes, and utensils must be maintained in a clean, sanitary, and safe manner . All areas of the dietary department will be cleaned on a regular schedule . 2. Review of the facility's kitchen cleaning schedule documented: .Sweep/mop under Everything . Each Shift . Deep Fryer . Daily . BEFORE LEAVING ON SUNDAY MAKE SURE THERE IS NOTHING ON THE FLOOR . 3. Observations in the kitchen on 8/18/14 at 9:38 AM, revealed 3 individual butter containers and dust on the floor under the fryer; splattered grease on the floor, on the sides and back splash of the fryer. 4. Observations in the kitchen on 8/19/14 at 11:05 AM, revealed the 3 individual butter containers and dust on the floor under the fryer; splattered grease on the floor, on the sides and back splash of the fryer was still present during the second day of the survey. 5. During an interview in the kitchen on 8/19/14 at 11:05 AM, the Dietary Manager was asked should the area around the fryer be clean. The Dietary Manager stated, Yes.	2018-02-01
9365	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2013-05-22	278	D	0	1	PLOD11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for hospice care, pressure sores and/or falls 2 of 35 (Residents #20 and 53) sampled residents included in the stage 2 review. The findings included: 1. Medical record review for Resident #20 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].D/C (discharge) from Skilled Services to Hospice on 2/24/13 Hx (history) Dx (diagnosis) Lung CA (cancer) . Review of a significant change MDS dated [DATE] documented, .Section O . Special Treatments, Procedures, and Programs . Check all of the following treatments, procedures, and programs that were performed during the last 14 days . K. Hospice care . The box for hospice care was not checked. During an interview at the skilled nurses' station on 5/21/13 at 2:30 PM, Nurse #3 was asked to find the current order for hospice care for Resident #20. Nurse #3 stated, Here it is written on 2/22/13 . During an interview in the MDS office on 5/22/13 at 8:00 AM, MDS Nurse #2 stated, .we have to do a sig (significant) change on them when they go into hospice . MDS Nurse #1 was asked if the MDS was coded for hospice. MDS Nurse #1 stated to MDS nurse #2, .no you forgot to mark it . 2. Medical record review for Resident #53 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #53's nurses' notes dated 2/20/13 documented a 4:30 PM admission note that included, .also noted to inner buttocks 1.3 cm (centimeters) X (by) 0.3 cm open area . Review of the admission MDS assessment, dated 2/27/13 documented, .M0210. Unhealed Pressure Ulcer(s) . Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher . This pressure sore question was coded with a 0, indicating No. During an interview at the 500 hallway nurse's station on 5/21/13 at 8:10 AM, Nurse #2 stated Resident #53 was admitted with a Stage 1 to Stage 2 area with excoriation to buttocks. During an interview in the MDS office on 5/22/13 at 2:00 PM, MDS Nurse #2 confirmed the MDS dated [DATE] documented no pressure sores were assessed on admission. Further review of the nurses' notes for Resident #53 dated 4/6/13 documented the resident was found on floor at 6 PM. Review of the quarterly MDS assessment dated [DATE] documented, .J1800. Any Falls Since . Prior Assessment . This fall question was coded with 0, indicating No. During an interview in the MDS office on 5/22/13 at 2:00 PM, MDS Nurse #2 verified Resident #53's MDS was inaccurate, no fall was documented.	2017-01-01
9366	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2013-05-22	279	D	0	1	PLOD11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, it was determined the facility failed to have a care plan for vision for 1 of 35 (Resident #62) sampled residents included in the stage 2 review. The findings included: Medical record review for Resident #62 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets ((MDS) dated [DATE] and 10/26/12 documented, Section B - Hearing, Speech, Vision . B0100 impaired - see large print but not regular print . Review of care plan dated 10/19/12 did not included care for vision. Observations in Resident #62's room on 5/21/13 at 8:00 AM, revealed Resident #62 sitting on side of bed working a puzzle using a magnifying glass. During an interview in Resident' #62's room on 5/22/13 at 7:45 AM, Resident #62 stated, I picked out me some frames for some glasses last week . I can't wait till (until) they (glasses) get here . During an interview in the MDS office on 5/22/13 on 9:00 AM, MDS Nurse #1 was asked should vision be care planned. MDS Nurse #1 stated, .vision should be in the care plan and it is not there .	2017-01-01
9367	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2013-05-22	309	D	0	1	PLOD11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review and interview, it was determined the facility failed to ensure physician orders [REDACTED].#125) sampled residents included in the stage 2 review. The findings included: Review of the facility's Lab (laboratory) and Diagnostic Test Results-Clinical Protocol policy documented, .The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs . Medical record review for Resident #125 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the original physician's orders [REDACTED].#125 documented, .LAB ORDERS . CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) EVERY 6 MONTHS . The facility was unable to provide results of the CBC and BMP that were due in 3/13. During an interview in the conference room on 5/22/13 at 10:50 AM, the Director of Nursing (DON) was asked for the results of the CBC and BMP that was due in 3/13. The DON stated, .it's (3/13 lab work) not there . it wasn't done .	2017-01-01
9368	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2013-05-22	314	D	0	1	PLOD11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure pressure sore treatments were done for 1 of 2 (Resident #67) sampled residents reviewed with pressure ulcer of the 35 residents included in the stage 2 review. The findings included: Review of the facility's treatment of [REDACTED]. Responsibilities of team members include . Documentation . Medical record review for Resident #67 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Telephone Orders dated 5/3/13 documented, .Apply . Zinc Vaseline 1: (to) 1:1 comp (composition) to sacral area BID (two times a day) & (and) PRN (as needed) till (until) resolved . Review of the treatment record dated 5/3/13 through 5/31/13 revealed there was no pressure sore treatment documented for 5/15/13 and 5/16/13 on the 6:00 PM to 6:00 AM shift. Review of the Minimum Data Set ((MDS) dated [DATE] documented, .Section M Skin Conditions . M0700. Most Severe Tissue Type for Any Pressure Ulcer . 2. Granulation tissue . Observations in Resident #67's room on 5/21/13 at 3:30 PM, revealed Resident #67 with a stage 2 pressure sore on the sacrum area. During an interview in 400 hall nurses' station on 5/21/13 at 2:00 PM, Nurse #1 was asked should pressure sore treatments be documented. Nurse #1 stated, Yes . it (pressure sore treatments) should be documented on the treatment record . During an interview in 400 hall nurses' station on 5/21/13 at 3:00 PM, Nurse #2 was asked should pressure sore treatments be documented. Nurse #2 stated, .when treatments are done they should be documented on the treatment record . Nurse #2 was asked to verify the missing documentation for the pressure sore treatment on the treatment record for 5/15/13 and 5/16/13. Nurse #2 stated, .if (treatments were) done, it was not documented .	2017-01-01
10878	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2013-04-30	309	D	1	0	SKV011	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Intakes: TN 563 Based on medical record review and interview, it was determined the facility failed to administer intravenous (IV) medications according to physician's orders [REDACTED].#6) sampled residents. The findings included: Medical record review for Resident #6 documented a original admission date of [DATE] with a readmission date of [DATE] post hospitalization with [DIAGNOSES REDACTED]. Review of the Physician Admission / Monthly Orders form dated 3/21/13 documented, Meropenem 500mg (milligrams) IV (intravenous) Q (every) 12 hrs (hours) until 3/25/13. A telephone order dated 3/22/13 documented, (Symbol for change) Meropenem 500mg IV to Meropenem 500mg IM (intramuscular) q (every) 12 hrs x (times) 5 days. The facility staff failed to document that they notified the MD that Meropenem did not come in IM form. Review of the department notes revealed the following: a. 3/21/13 at 3:04 PM - IV antibiotic not available at this time. Begain (begin) when available . 3/21/13 at 11:59 PM - .IV ABT (antibiotic) was not given this p.m. Unable to restart INT (intermittent intravenous access) R/T (related to) poor venous access. Will inform (name of physician) of same in a.m. and await any new orders . b. 3/22/13 at 10:59 PM - .IV ABT not given this pm. unable to restart INT . c. 3/23/13 at 2:40 PM - Asked by Hall 3 nurse to attempt IV access d/t (due to) resident has orders for Meropenem 500mg IV every 12 hours until 3/25/13. Assessed resident for peripheral IV access. BUE (bilateral upper extremities) noted to be swollen and large. Multiple area of bruising noted and mulitpe (multiple) old IV sites noted. Did not attempt peripheral IV access. There was no documentation on 3/24/13 of attempts to start the IV to administer Meropenem 500 mg IV and no documentation of attempts to notify the physician of resident not receiving IV antibiotic as ordered. During a telephone interview on 4/29/13 at 2:15 PM, the Director of Nursing (DON) was asked if the physician was notified that the Meropenem did not come in an IM administration route. The DON stated, They (nurses) called on-call doctor at 5:00 PM that Friday. He said to try to access (IV) again . During a telephone interview on 4/29/13 at 4:12 PM, the DON was asked what was the expectation or the policy of the facility if the nurses were not able to access a site to administer IV medications. The DON stated the facility does not have a policy. The nurses would try a couple of sticks and then notify another nurse in the building to try to start the IV. Every nurse would get another nurse to try for about 24 hours and then call doctor to see if it could be changed to IM. During a telephone interview on 4/29/13 at 4:15 PM, the DON was asked if the physician was called on 3/23/13 to notify the physician the facility was unable to start the IV to administer Meropenem 500 mg IV every 12 hours. The DON stated a nurse called the on-call physician on Saturday (3/23/13) and the on-call physician stated to keep trying to get access. It was not charted. During a telephone interview on 4/30/13 at 1:50 PM, the DON was asked if the facility attempted to start the IV to administer the Meropenem 500 mg IV or if the physician was notified of the inability of the facility to start the IV to administer the Meropenem on 3/24/13. The DON confirmed there was no documentation in the department notes on 3/24/13 and stated, I don't know about Sunday . The facility failed to start the IV and administer the Meropenem 500 mg IV every 12 hours as ordered.	2016-04-01
10879	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2013-04-30	514	D	1	0	SKV011	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Intakes: TN 563 Based on medical record review and interview, it was determined the facility failed to maintain complete an accurate medical records for 1 of 6 (Resident #6) sampled residents. The findings included: Medical record review for Resident #6 documented a original admission date of [DATE] with a readmission date of [DATE] post hospitalization with [DIAGNOSES REDACTED]. Review of the Physician Admission / Monthly Orders form dated 3/21/13 documented, Meropenem 500mg (milligram) IV (intravenous) Q (every) 12 hrs (hours) until 3/25/13. Review of the department notes documented the following: a. 3/21/13 at 3:04 PM - IV antibiotic not available at this time. Begain (begin) when available . 3/21/13 at 11:59 PM - .IV ABT (antibiotic) was not given this p.m. Unable to restart INT (intermittent intravenous access) R/T (related to) poor venous access. Will inform (name of physician) of same in a.m. and await any new orders . Review of the Telephone Orders dated 3/22/13 documented, (Symbol for change) Meropenem 500mg IV to Meropenem 500mg IM (intramuscular) q (every) 12 hrs x (times) 5 days. The facility staff failed to document that they notified the MD that Meropenem did not come in IM form. Further review of the department notes documented the following: a. 3/22/13 at 10:59 PM - .IV ABT not given this pm. unable to restart INT . b. 3/23/13 at 2:40 PM - old IV sites noted. Did not attempt peripheral IV access . There was no documentation on 3/24/13 of attempts to start the IV to administer the Meropenem 500 mg IV and no documentation of attempts to notify the physician of the resident not receiving IV antibiotic as ordered. During a telephone interview on 4/29/13 at 2:15 PM, the Director of Nursing (DON) was asked if the physician was notified that the Meropenem does not come in an IM administration route. The DON stated, They (nurses) called the on-call doctor at 5:00 PM that Friday. He said to try to access (IV) again . The DON also confirmed the nurse did not document calling the physician and writing an order to change the route from IM back to IV. During a telephone interview on 4/29/13 at 4:15 PM, the DON was asked if the physician was called on 3/23/13 to notify the physician the facility was unable to start the IV to administer Meropenem 500 mg IV every 12 hours. The DON stated a nurse called the on-call physician on Saturday (3/23/13) and the on-call physician stated to keep trying to get access. It was not charted. The facility failed to ensure the medical record was accurate when the nurses failed to document that the MD was notified that Meropenem did not come in IM form and there was no documentation on 3/24/13 of attempts to start the IV to administer the Meropenem 500 mg IV and no documentation of attempts to notify the physician of the resident not receiving IV antibiotic as ordered.	2016-04-01
12070	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2012-02-23	279	D	0	1	40S411	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review and interview, it was determined the facility failed to develop an interim care plan in the first 24 hours of admission for 4 of 20 (Residents #4, 8, 11 and 12) sampled residents. The findings included: 1. Review of the facility's Care Plans----Preliminary policy documented, .A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four hours of admission. 2. Medical record review for Resident #4 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide an interim care plan for the admission date of [DATE]. The first documented care plan for Resident #4 was dated 12/28/11. 3. Medical record review for Resident #8 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide an interim care plan for the admission date of [DATE]. 4. Medical record review for Resident #11 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide a dated interim care plan for the readmission date of [DATE]. 5. Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide an interim care plan for the admission date of [DATE]. 6. During an interview in the conference room on 2/22/12 at 3:30 PM, the Director of Nursing (DON) was asked when should a care plan be initiated. The DON stated, .within the first 24 hours of admission.	2015-10-01
12071	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2012-02-23	280	D	0	1	40S411	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review and interview, it was determined the facility failed to revise the comprehensive care plan to reflect the current status of a resident with pressure ulcers for 1 of 20 (Resident #8) sampled residents. The findings included: Review of the facility's care plan policy documented, .plan of care. shall be developed. To assure that the resident's immediate care needs are met. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 7/18/11 had no documented interventions for the [DIAGNOSES REDACTED]. During an interview in the conference room on 2/22/12 at 3:30 PM, the Director of Nursing (DON) was asked when the care plan should be initiated. The DON stated, .within the first 24 hours.	2015-10-01
12072	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2012-02-23	282	D	0	1	40S411	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility failed to follow the care plan for turning, repositioning and skin care for 1 of 17 (Resident #8) sampled residents. The findings included: Medical record review for Resident #8 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 4/29/11 documented, .Prone to skin breakdown. turn every 2 hours while in bed. Resident #8's medical record contained documentation of a hospitalized from [DATE] through 7/18/11 with a [DIAGNOSES REDACTED]. The facility was unable to provide documentation that the resident was turned and repositioned every two hours. During an interview in the conference room on 2/23/12 at 2:30 PM, the Director of Nursing (DON) was asked if there was documentation to verify that the resident was turned and repositioned every two hours. The DON stated, No. I don't think we have anything in the computer for that. The DON was asked if the facility had a policy for turning and repositioning a resident at risk for skin breakdown. The DON stated, There is no policy for turning every two hours.	2015-10-01
12073	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2012-02-23	309	E	0	1	40S411	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review and interview, it was determined the facility failed to follow physician's orders for constipation for 4 of 20 (Residents #3, 11, 15 and 16) sampled residents. The findings included: 1. Review of the facility's Tri-County Healthcare Standing Physician Orders documented, .3. Stool Softener/Laxative: PRN (as needed) Constipation. a. [MEDICATION NAME] S: 1 pill at HS (hour of sleep) prn. b. MOM (milk of magnesia) 30 ml (milliliters) prn. c. [MEDICATION NAME]: 2 tabs (tablet) prn. d. [MEDICATION NAME] tabs: 2 at HS prn. e. [MEDICATION NAME] Suppository 1 PR (per rectum) prn. f. Check for impaction prn and remove if indicated. 4. Enema of choice prn: Severe constipation. 2. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #3's BM (bowel movement) Detail option 2 Roster had no BM documented from 10/18/11 through (-) 10/25/11 and from 11/27/11 - 12/1/11. The Medication Administration Record [REDACTED]. The facility failed to implement the physician's standing orders for constipation. 3. Medical record review for Resident #11 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #11's BM Detail option 2 Roster had no BM documented from 2/1/11 - 12/8/11, 1/8/12 - 1/12/12, 1/13/12 - 1/23/12, 1/23/12 - 2/2/12 and 2/12/12 - 2/18/12. The MAR indicated [REDACTED]. 4. Medical record review for Resident #15 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #15's BM - Yes/No (Only) Roster had no BM documented from 2/5/12 - 2/9/12. The facility failed to implement the physician's standing orders for constipation. During an interview in the conference room on 2/23/12 at 10:50 AM, the Director of Nursing (DON) was asked to review Resident #15's bowel movement record. The DON stated, .He (Resident #15) should have received something (for lack of a BM). Expect the nurse to review the BM record, if no BM third day they are to start the standing orders for constipation. 5. Medical record review for Resident #16 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. The physician's recertification orders dated 12/1/11 through 12/31/11 documented, .Milk of Magnesia Suspension take 30 ml by mouth as needed. Resident #16's BM Detail option 2 Roster had no BM documented from 12/5/11 - 12/9/11 and 12/24/11 - 12/28/11. The MAR indicated [REDACTED]. The physician's recertification orders dated 1/1/12 through 1/31/12 documented, .Milk of Magnesia Suspension take 30ml by mouth as needed. Resident #16's BM Detail option 2 Roster had no BM documented from 1/11/12 - 1/17/12 and from 1/29/12 - 2/1/12. The MAR indicated [REDACTED]. Review of the physician's recertification orders dated 2/1/12 through 2/29/12 documented, .Milk of Magnesia Suspension take 30ml by mouth as needed. Resident #16's BM Detail option 2 Roster had no BM documented from 2/18/12 - 2/22/12. The MAR indicated [REDACTED]. 6. During an interview in the conference room on 2/23/12 at 8:15 AM, the DON was asked who is responsible for the bowel management of the residents. The DON stated, .Nursing is to review the BM record per each unit. Expect Nursing to review the BM record and if no BM by third day begin the standing orders for constipation and if patient is on a stool softener then should go to the next level [MEDICATION NAME]	2015-10-01
12074	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2012-02-23	314	D	0	1	40S411	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Clinical Practice Guidelines, policy review, medical record review and interview, it was determined the facility failed to follow the care plan intervention to turn every two hours to prevent the development of a pressure ulcer for 1 of 3 (Resident #8) sampled residents with pressure ulcers. The findings included: Review of the NPUAP Clinical Practice Guidelines documented, .Any individual in bed who is assessed to be at risk for developing pressure ulcers should be repositioned at least every 2 hours. A written schedule for systematically turning and repositioning the individual should be used. Review of the facility's Skin Program Policy documented, .The nursing department coordinates the response to patient needs.with an array of preventative measures practiced on the resident's behalf when the resident has been identified as being at risk. Medical record review for Resident #8 documented an admission date of [DATE] with readmitted s of 7/18/11 and 8/19/11 and [DIAGNOSES REDACTED]. Review of the care plan documented an approach dated 6/17/11 for Staff to turn and repo (reposition) res (resident) q2hrs (every two hours) and prn (as needed). Review of Weekly Skin Integrity Assessment dated 7/9/11 documented, .Skin Condition Dry. Skin Intact. Review of a nurse's note dated 7/10/2011 documented, .reddened area to buttocks with bluish and blackened areas, with blisters. 2 small opened areas. Review of a nurse's note dated 7/11/2011 documented, .no change to residents buttocks, blistered area still dark discoloration, serosanguenous drainage present. The facility was unable to provide documentation that the resident was turned and repositioned every two hours. During an interview in the conference room on 2/23/12 at 2:30 PM, the DON was asked if there was documentation to verify that the resident was turned and repositioned every two hours. The DON stated, No. I don't think we have anything in the computer for that. The DON was asked if the facility had a policy for turning and repositioning a resident at risk for skin breakdown. The DON stated, There is no policy for turning every two hours.	2015-10-01
12075	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2012-02-23	441	E	0	1	40S411	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Association for Professionals in Infection Control and Epidemiology (APIC) Guide to the Elimination of Clostridium difficile in Healthcare Settings, policy review, medical record review, cleaning product efficacy review, observation and interview, it was determined the facility failed to ensure practices to prevent the potential spread of infection were maintained by utilizing an ineffective cleaning product for 4 of 4 (Residents #8, 14, 19 and 20) sampled residents with Clostridium difficile infection. It was also determined the facility failed to ensure practices to prevent the potential spread of infection when staff members failed to practice sanitary hand hygiene during 1 of 2 dining observations and during catheter care for sampled Resident #6. The findings included: 1. Review of the APIC Guide to the Elimination of Clostridium difficile in Healthcare Settings documented, .Disinfectants commonly used in healthcare settings include quaternary ammoniums and [MEDICATION NAME], neither of which are sporicidal. only chlorine-based disinfectants. kill spores. Review of the facility's Cleaning, Disinfection and Sterilization policy documented, .provide supplies and equipment that are adequately cleaned, disinfected or sterilized. a. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. diff (Clostridium difficile - an intestinal bacteria which has spores that can live on inanimate objects, such as beds and overbed tables, for up to six months). b. Medical record review for Resident #14 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. diff. c. Medical record review for Resident #19 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a discharge summary dated 2/23/11 documented, .resident developed [DIAGNOSES REDACTED] at (name of local hospital) .admitted into isolation. d. Medical record review for Resident #20 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. diff culture. During an interview in the unit 3 hallway on 2/22/12 at 12:30 PM, the Director of Environmental Services (DES) was asked which cleaning product was used for daily cleaning of [DIAGNOSES REDACTED] contact isolation rooms. The DES replied, .Broad-Cide. it kills everything. The DES was asked how long the contact time was for killing [DIAGNOSES REDACTED]. The DES stated, .there is no contact time for killing. The DES was asked which cleaning product was used for terminal cleaning of [DIAGNOSES REDACTED] contact isolation rooms. The DES replied, .Broad-Cide. The DES confirmed Broad-Cide is not a chlorine-based disinfectant. Review of the active ingredients of Broad-Cide 128 documented, Didecyl [MEDICATION NAME] ammonium chloride. The product that the facility use for cleaning did not effectively disinfect the organism of [DIAGNOSES REDACTED]. 2. Observations during meal tray pass in room [ROOM NUMBER] on 2/22/12 at 12:21 PM, Certified Nursing Assistant (CNA) #2 touched the resident's wheelchair legs and base of the overbed table, then prepared the meal tray without washing her hands. Observations during meal tray pass in room [ROOM NUMBER] on 2/22/12 at 12:30 PM, revealed CNA #1 moved the resident's chair and repositioned the resident, then prepared the meal tray without washing her hands. During an interview in the Director of Nursing's (DON) office on 2/22/12 at 5:00 PM, the DON was asked what is the expectation of hand hygiene if the staff touch the resident's environment. The DON confirmed the staff is to wash their hands after touching the resident's environment before preparing the meal tray. 3. Observations during catheter care for Resident #6 on 2/22/12 at 4:20 PM, revealed CNA #1 completed Foley catheter care and without changing her contaminated gloves touched the bed controls, resident's pillow, bed linen and overbed table, then removed her gloves. During an interview in the DON's office on 2/22/12 at 5:00 PM, the DON was asked what is the expectation of staff changing gloves and handwashing when going from a dirty area to a clean area during Foley catheter care. The DON state that she expects staff to change their gloves and wash hands when going from a dirty area to a clean area when providing care.	2015-10-01
13806	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2010-12-01	332	E	0	1	IDW711	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observations and interviews, it was determined the facility failed to ensure 3 of 6 (Nurses #3, 5 and 6) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 5 errors were observed out of 40 opportunities, resulting in a medication error rate of 12.5%. The findings included: 1. Review of the facility's "Administering Medications through a Metered Dose Inhaler" policy documented, "...Allow at least one (1) minute between inhalations of the same medication..." Medical record review for Random Resident (RR) #1 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in RR #1's room on 11/29/10 at 11:45 AM, revealed Nurse #3 administered two puffs of a [MEDICATION NAME] inhaler to RR #1. Nurse #3 did not pause between the puffs. Failure to pause at least one minute between the puffs resulted in medication error #1. 2. Medical record review for Resident #6 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #6's room on 11/30/10 at 6:25 AM, revealed Nurse #6 administered one eye into each of Resident #6's eyes. Failure to administer two eye drops into each eye resulted in medication error #2. During an interview on side three on 11/30/10 at 8:20 AM, Nurse #6 stated, "You're right I should have given two drops and I only gave one." 3. Review of the facility's "Insulin Administration" policy documented, "...8. Check the order for the amount of insulin..." Medical record review for Resident #16 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #16's room on 11/30/10 at 7:15 AM, Nurse #6 performed a fingerstick blood sugar (FSBS) on Resident #16's with results of 120. Nurse #6 administered [MEDICATION NAME] R 2 units to Resident #16. The administration of 2 units of [MEDICATION NAME] R insulin resulted in medication error #3. During an interview on side 3 on 11/30/10 at 11:55 AM, the Director of Nursing stated, "It (referring to insulin dosage) was a transcription error. We did incident report, notified doctor and checked all other orders, didn't find any other problems." 4. Review of the facility's "Insulin Administration" policy documented, "...6. Gently roll the insulin vial between palm of both hands to resuspend the insulin..." a. Medical record review for Resident #15 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].M. @ (at) 6:45 AM (2) Bedside Glucose time change to 645 AM, 1130 AM, 445 PM, 800 PM c (with) [MEDICATION NAME] 5 units SQ (subcutaneous) as ordered due to mealtime changes to begin 11/17/10." Review of a physician's orders [REDACTED].@ 6:45 am." Observations in Resident #15's room on 11/30/10 at 6:45 AM, revealed Nurse #5 administered [MEDICATION NAME] 70/30 25 units to Resident #15. Nurse #5 did not roll the insulin vial to resuspend the insulin prior to drawing up the insulin. Failure to roll the insulin vial resulted in medication error #4. b. Medical record review for Resident #10 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #10's room on 11/30/10 at 7:20 AM, Nurse #6 administered [MEDICATION NAME] 70/30 165 units to Resident #10. Nurse #6 did not roll the vial of insulin prior to drawing up the insulin to resuspend the insulin. Failure to roll the vial of insulin resulted in medication error #5.	2014-09-01
13807	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2010-12-01	465	E	0	1	IDW711	Based on observations and interviews, it was determined the facility failed to ensure the environment was clean and sanitary as evidenced by a soiled shower chair, a dark brown buildup on the tile, and feces on the drain in the shower stall in 2 of 2 (Shower rooms 1 and 2) shower rooms. The findings included: 1. Observations in Shower #2 on 11/29/10 at 9:35 AM and 3:25 PM and on 11/30/10 at 3:15 PM, revealed a clump of dark brown substance on the drain in the shower stall and a dark brown buildup covering the tile near the drain. During an interview in Shower #2 on 11/30/10 at 3:15 PM, Housekeeper #1 was asked what the dark brown buildup on the tile was and what was the brown substance on the drain. Housekeeper #1 stated, "I don't know what that is on the tile. It has been there for awhile. That's BM (bowel movement) on the drain." 2. Observations in Shower #1 on 11/29/10 at 3:35 PM and on 11/30/10 at 3:15 PM, revealed a bariatric shower chair in the shower stall with the safety belts soiled with brown stains. During an interview in Shower #1 on 11/30/10 at 3:15 PM, the Housekeeping Supervisor was asked if the shower chair was clean. The Housekeeping Supervisor stated, "No and I wouldn't want that belt around me. It's dirty."	2014-09-01
13808	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2010-12-01	334	D	0	1	IDW711	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, it was determined the facility failed to provide the influenza vaccine for 1 of 22 (Resident #7) sampled residents. The findings included: Review of the facility's "Vaccination of Residents" policy documented, "...Influenza Vaccination... all residents will be offered an influenza vaccine beginning in October of each year, unless medically contraindicated or the resident has already been vaccinated..." Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's telephone order dated 10/7/10 documented, "...Flu vac (vaccine) 0.5 ml (milliliters)..." The facility was unable to provide documentation that the flu vaccine had been administered to Resident #7. During an interview at the side 3 nurse's station on 11/29/10 at 2:40 PM, Nurse #8 was asked if Resident #7 received the flu vaccine. Nurse #8 reviewed the medical record and stated, "...It should have been documented on the MAR (medication administration record), nurse's notes, and care plan. I don't see that. I'm not sure that she got it."	2014-09-01
13809	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2010-12-01	431	D	0	1	IDW711	Based on policy review, observations, and interviews, it was determined the facility failed to ensure a medication cart was locked and medications were not left unattended in 1 of 8 (Side 2 medication cart) medication storage areas. The findings Included: Review of the facility's "Storage of Medications" policy documented, "...The facility shall store all drugs and biological in a safe, secure, and orderly manner... Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biological shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others..." Observations on side 2 on 11/30/10 at 7:00 AM, revealed the side 2 medication cart was left unattended, unlocked and out of view of the nurse. Observations on side 2 on 11/30/10 at 7:31 AM, revealed a vial of Novolin 70/30 insulin was sitting on top of side 2's medication cart unattended. During an interview on side 2 on 11/30/10 at 7:10 AM, the surveyor told Nurse #6 that she had left the side 2 medication cart unlocked. Nurse #6 stated, "I know it's a bad habit, when I just step right in there (referring to resident's room) I forget." During an interview in the conference room on 12/1/10 at 10:00 AM, the Director of Nursing stated, "Med (medication) cart should always be locked."	2014-09-01
13810	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2010-12-01	282	D	0	1	IDW711	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, and interviews, it was determined the facility failed to follow interventions on the care plan for floor mats and a pressure relief mattress for 1 of 22 (Residents #5) sampled residents. The findings included: Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive care plan dated 1/27/10 documented, "...pressure relief mattress for comfort and prevention..." and dated 2/25/10 documented, "...low bed with mats in place..." Observations in Resident's #5's room on 11/29/10 at 4:00 PM and on 11/30/10 at 8:30 AM,10:05 AM, 12:05 PM and 2:20 PM, revealed there were no floor mats and a pressure relief mattress in place for Resident #5. During an interview in Resident #5's room on 11/30/10 at 2:40 PM, Nurse #7 verified there were no floor mats or a pressure relief mattress present. During an interview at side 1 nurses' station on 11/30/10 at 2:45 PM, the Director of Nursing confirmed that floor mats and pressure relief mattress were on the care plan but were not implemented for Resident #5.	2014-09-01
13811	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2010-12-01	309	D	0	1	IDW711	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews, it was determined the facility failed to follow physician orders [REDACTED].#17 and 19) sampled residents. The findings included: 1. Medical record review for Resident #17 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].= (amount of insulin to be administered 18 AND CALL MD (Medical Doctor) IF NO RESULTS..." Review of the July 2010 diabetic record for Resident #17 revealed the following BS's above 300 that were not rechecked to determine the results of the insulin administered: a. 7/10/10-4:30 PM, BS-354. b. 7/15/10-4:30 PM, BS-314. c. 7/15/10-8:00 PM, BS-338. d. 7/17/10-11:30 AM, BS-321. e. 7/17/10-8:00 PM, BS-314. f. 7/21/10-11:30 AM, BS-311. g. 7/21/10-8:00 PM, BS-397. h. 7/22/10-11:30 AM, BS-307. i. 7/23/10-4:30 PM, BS-400. j. 7/23/10-8:00 PM, BS-381. k. 7/26/10-8:00 PM, BS-328. l. 7/28/10-4:30 PM, BS-310. m. 7/29/10-7:30 AM, BS-305. n. 7/29/10-8:00 PM, BS-380. o. 7/30/10-8:00 PM, BS-318. During an interview in the conference room on 12/1/10 at 10:45 AM, Nurse #8 stated, "They need to recheck it (BS) to see if the BS has gone down, that's the only way to know the results. Usually recheck it in 45 minutes to an hour unless the doctor has a specific order." 2. Medical record review for Resident #19 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. A physician's telephone order dated 10/4/10 documented, "...Give Nov ([MEDICATION NAME]) R 15 u now Recheck in 2 hrs (hours) for BS 442..." The physician's orders [REDACTED]." Review of the October 2010 medication administration record (MAR) for Resident #19 documented the following BS results: a. 10/4/10 8 PM BS 441. b. 10/15/10 5:30 PM BS 433. The facility was unable to provide documentation of rechecks in 2 hrs of a BS over 400. Further medical record review revealed a physician's telephone order dated 10/4/10 documented, "...Give Nov R 15 u now Recheck in 2 hrs (hours) for BS 442..." Review of the daily skilled nurses notes documented, "...10/4/10 12:00 AM Rechecked blood sugar c result of 442. Called MD was ordered to give 16 units Nov R now then recheck in 2 hrs..." There was no documentation the BS was rechecked in 2 hours after administering the insulin. During an interview at the side 1 nurse's station Nurse #8 reviewed Resident #19's MAR and the nurses notes and stated, "...She (medication nurse) didn't recheck (BS) in 2 hrs..."	2014-09-01
13812	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2010-12-01	280	D	0	1	IDW711	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interviews, it was determined the facility failed to revise the comprehensive care plan for care of emergency bleeding for 2 of 22 (Resident #18 and 19) sampled residents. The findings included: 1. Review of the facility's "[MEDICAL TREATMENT], [MEDICAL TREATMENT]" policy documented, "...Check graft site for bleeding upon return post-[MEDICAL TREATMENT] and per MD (Medical Doctor) orders. If bleeding occurs, apply direct pressure until controlled. Notify MD and DON (Director of Nursing) if bleeding lasts longer than 30 minutes or is severe initiate EMS (Emergency Management Service) system." 2. Medical record review for Resident #18 documented an admitted [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 1/26/10 documented "[MEDICAL TREATMENT] as ordered. Assess site... q (every) d (day) for s/s (signs and symptoms) inf. (infection) or bleeding assess for thrill/bruit q shift..." The care plan did not address measures to be put in place to stop emergency bleeding. During an interview at the side 3 nurses' station on 12/1/10 at 1:00 PM, Nurse #9 stated, "(Care plan) says to check for it (emergency bleeding) but doesn't really say what to do for it." 3. Medical record review for Resident #19 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 2/23/10 documented "...Check shunt or port site for s/s of infections, pain or bleeding daily and PRN (as needed)..." The care plan did not address measures to be put in place to stop emergency bleeding. During an interview at the side 1 nurses' station on 12/1/10 at 1:52 PM, the DON stated, "It (care plan) should have interventions for a bleed but it wasn't included."	2014-09-01
13813	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2010-12-01	441	E	0	1	IDW711	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy reviews, observations, and interviews, it was determined 5 of 24 staff members (Certified Nursing Assistants (CNA) #1, CNA #2, Rehabilitation Coordinator, Dietary Manager and Nurse #2) failed to ensure infection control practices were used to prevent the potential spread of infection by not using sanitary hand hygiene or touching food and straws with their bare hands. Two (2) of 6 nurses (Nurses #5 and #6) failed to clean the glucometer with a Super Sani-wipe. The findings included: 1. Review of the facility's "Hand-hygiene" policy documented, "...2. hand washing ...b. after contact ...with non-intact skin... d. before and after eating or handling food... 3. a. before or after direct contact with residents... g. after contact with resident's intact skin... i. after contact with inanimate objects (...equipment) in the immediate vicinity of the resident..." a. Observations in room [ROOM NUMBER] A on 11/30/10 at 7:45 AM, CNA #1 held the toast with his bare hand to put jelly and butter on it. Observations in room [ROOM NUMBER] A on 11/30/10 at 12:15 PM, CNA #1 removed a slice of bread from the wrapper with her bare hands. Observations in room [ROOM NUMBER] B on 11/30/10 at 12:20 PM, CNA #1 removed a slice of bread from the wrapper with her bare hands, opened the straw and touched the straw with her bare hand. b. Observations in room [ROOM NUMBER] on 11/30/10 at 7:18 AM, CNA #2 repositioned a resident, adjusted the bed with the bed control and moved a box under the bed and then began to set up the tray opening the butter and the sweetner. CNA #2 then began to fed the resident. CNA #2 did not wash her hands prior to tray set up or before she fed the resident. Observations in room [ROOM NUMBER] on 11/30/10 at 7:40 AM, CNA #2 did not wash her hands prior to delivery of the meal tray or prior to opening the milk and butter. CNA #2 left the room and proceeded to get the next tray without washing hands. Observations in room [ROOM NUMBER] on 11/30/10 at 7:45 AM, CNA #2 opened the straw and touched the straw with her bare hand. Observations in room [ROOM NUMBER] on 11/30/10 at 7:47 AM, CNA #2 opened the straw and touched the straw with her bare hand. Observations in room [ROOM NUMBER] on 11/30/10 at 7:50 AM, CNA #2 repositioned the resident, manipulated the pillow and bed linen and did not wash her hands prior to setting up the food tray. CNA #2 then touched the straw with her bare hand, and began feeding the resident. c. Observations in the main dining room on 11/30/10 at 11:30 AM, the Rehabilitation Coordinator opened a resident's straw and touched the straw with her bare hand then went to another resident and opened another straw with her bare hand. d. Observations in the main dining room on 11/30/10 at 11:30 AM, the Dietary Manager opened a resident's straw and touched the straw with her bare hand. e. During an interview at side 3 nurses' station on 12/1/10 at 7:45 AM, the Staffing Coordinator was asked what is the expectation of staff when passing meal trays. The Staffing Coordinator stated, "Wash hands prior to tray delivery, if touch resident or their environment will need to wash hands again. Don't touch straw or food with bare hands..." f. Observations in Resident #17's room on 11/29/10 at 11:48 AM, revealed Nurse #2 did not wash her hands after administering an injection. 2. Review of the facility's "Blood Glucose Meter Maintenance Policy & (and) Procedure" documented, "...Purpose: The Blood Glucose Meter should be cleaned and disinfected between each resident use... Procedure...2b. Take a clean wipe and thoroughly wipe and wet surface to disinfect. 3. When using the wipes to clean and disinfect the meter...follow all product label instructions. (2 minute dry Super Sani-wipes)..." a. Observations in Random Resident (RR) #5's room on 11/30/10 at 6:35 AM, Nurse #5 cleaned the glucometer with an alcohol pad not with a Super Sani-wipe as per policy. Observations in Resident #15's room on 11/30/10 at 6:45 AM, Nurse #5 cleaned the glucometer with an alcohol pad not with a Super Sani-wipe as per policy. After use of the glucometer Nurse #5 returned the glucometer to the medication cart drawer without cleaning it. b. Observations in Resident #7's room on 11/30/10 at 7:00 AM, Nurse #6 did not clean the glucometer prior to or after obtaining a blood glucose on Resident #7. Nurse #6 then entered Resident #16's room at 7:15 AM, Nurse #6 obtained a blood sugar with the same glucometer used on Resident #7 without cleaning it before or after use. Nurse #6 then entered Resident #10's room at 7:20 AM, with the same contaminated glucometer Nurse #6 obtained a blood sugar on Resident #10. Nurse #6 did not clean the glucometer prior to use on each resident nor did she clean the glucometer between residents or after each use. During an interview in the conference room on 12/1/10 at 10:00 AM, the Director of Nurses (DON) was asked what is the expectation of cleaning the glucometer. The DON stated, "They (nurses) should clean it (glucometer) between residents and are to clean it with the Sani-wipe cloths. We have packets made up and there is no excuse for that (not cleaning the glucometer prior to of after each use). They (nurses) can do better."	2014-09-01
13814	ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER	445397	409 PARK AVENUE	ADAMSVILLE	TN	38310	2010-12-01	371	E	0	1	IDW711	Based on policy review, observations, and interviews, it was determined the facility failed to ensure that staff had hair and beards covered in the kitchen on 2 of 3 (11/29/10 and 12/1/10) days and that dishes were air dried on 1 of 3 (11/29/10) days of kitchen observations. The findings included: 1. Review of the facility's "DRESS CODE" policy documented, "...B. Dietary staff ...Hair Nets..." Observations in the kitchen on 11/29/10 at 9:00 AM and 1:55 PM, revealed dietary staff #1 working at the ware washer and on the tray line. Dietary staff member #1's beard was not covered. Observations in the kitchen on 12/1/10 at 7:55 AM, revealed dietary staff member #1 was working on the tray line with his beard not covered. Observations in the kitchen on 12/1/10 at 7:55 AM, revealed dietary staff member #3 stocking supplies in the kitchen. Dietary staff member #3 was wearing a cap that partially covered his hair and his beard was not covered. Observations in the kitchen on 12/1/10 at 8:15 AM, revealed dietary staff members #1 and #3 were in the kitchen with no beard coverings on and dietary staff member #3's hair was partially uncovered. During an interview in the kitchen on 12/1/10 at 8:15 AM, the Dietary Manager (DM) was asked about hair coverings. The dietary manager stated, "They (staff members) wear caps but no beard covers. I don't think our policy says anything about beard covers." The dietary manager agreed that the facial hair was not covered. 2. Review of the facility's "Departmental Policies" documented, "...All pots and pans must be air dried after the final sanitizing rinse..." Observations in the kitchen on 11/29/10 at 9:00 AM, revealed dietary staff member #1 was removing clean dishes from the ware washer and drying the dishes with a towel. Observations in the kitchen on 11/29/10 at 1:55 PM, revealed dietary staff member #2 was removing clean dishes from the ware washer and drying the dishes with a towel. During an interview in the dietary office on 12/1/10 at 8:10 AM, the DM was asked about drying the dishes with a towel. The DM stated, "I thought it was okay to dry if you change towels when they (towels) are damp."	2014-09-01
659	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2018-03-14	565	E	1	0	2X2811	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on review of the Resident Council Meeting Minutes, medical record review, observations, and interviews the facility failed to ensure the residents' concerns/grievances related to staffing and call light response time were promptly acted upon for residents who attended resident council meetings, and for two (Resident #5 and #13) of six residents (Residents #1, #3, #5, #9, #12, and #13) sampled for quality of care. The findings included: Review of the resident Council Meeting Minutes for the past six months (October (YEAR) - (MONTH) (YEAR)) revealed the following: On 10/4/17 one resident stated he was not being changed at night on the second to third shift. He stated the facility needed more nurses and aides. On 11/1/17 one resident stated he was not being changed at night on the third shift. The minutes indicated, Multiple residents at the meeting complained of late night/early morning staff not answering call lights. On 12/6/17 one resident stated he was still not being changed on the second and third shift. The minutes indicated, Residents stated some staff just walks in the room and turns call light off and walks out without asking what they need. On 1/3/18 the minutes indicated, Residents stated call lights were still being turned off at times without finding out what the problem is. They also stated that if the call lights were answered it took a while to be answered. One resident stated if the call light was answered, some staff said they would be back, but did not come back or came back 1 to 2 hours later. On 2/7/18 the residents stated they felt the call lights could be answered timelier on the first and third shifts. On 3/7/18 one resident stated her call light was not being answered timely and one resident stated he was not being changed. Continued review revealed none of the Resident Council Meeting minutes included documentation of previous concerns raised by the group and what action had been taken to resolve them. Observation on 3/13/18 at 5:45 AM of the available staffing revealed the facility had a census of 76 residents; had a total of two certified nurse aides (CNA) #1 and CNA #2; and two licensed practical nurses (LPN) #1 and LPN #6 in the facility. Continued observation and interview with CNA #2 on 3/13/18 at 6:10 AM in the hallway revealed, they were supposed to have three CNAs working; however, one called in and that left just she and another CNA to care for 76 residents. She stated the LPNs helped when they could; however, they were still unable to meet the needs of the residents timely when they only had two aides on duty. CNA #2 was asked if any of the residents experienced falls or were not able to make it to the bathroom on time due to not having the third CNA to help. CNA #2 stated Resident #13 was not assisted to the bathroom timely and had a bowel movement in her incontinence brief when she normally made it to the bathroom on time and voided on the toilet. Medical record review for Resident #13 revealed she had [DIAGNOSES REDACTED]. Review of the admission nursing assessment, dated 3/3/18 revealed she did not show signs of cognitive loss or communication limitations; she required assistance with all her activities of daily living (ADLs). Her plan of care with an effective date of 3/5/18 stated she had an ADL self-care problem because she required assistance with some ADLs. Interview with Resident #13 her room on 3/13/18 at 8:15 AM, confirmed she had been in the facility for a little over a week and she felt she could, get better care at home. She stated when she put her call light on it, takes forever to get help. She stated she put her call light on last night because she needed to have a bowel movement (BM) and waited 10 minutes in her bed and when no one came and she could not hold it any longer she got up by herself with her walker to go to the bathroom. She stated her doctor told her not to get up without help because of her blood pressure, but she had no choice. She stated, just as she stood up she had an accident and got (BM) on the floor and in her brief. She stated once she got into the bathroom, she put the call light on because she had BM up her back and she needed help to get cleaned up. She stated she had to wait 20 more minutes while sitting on the toilet in the bathroom before staff arrived. The resident stated she found it frustrating to have to wait. Observation and interview on 3/12/18 at 3:44 PM with Resident #5 in his room revealed the facility needed more staff on the third shift. He stated, It just seems like there were no staff in the building on night shift. When asked if his call light was answered timely, he stated it took a while for it to get answered, but did not state how long. Review of Resident #5's Admission MDS assessment revealed he had a BIMs score of 14 (indicating he was cognitively intact). Interview on 3/14/18 at 9:48 AM the Director of Nursing and the Administrator in the activity room revealed the Administrator was asked about how complaints from the resident council were handled. The Administrator stated after the resident council meeting, the department heads were given the complaints about their areas and they were supposed to address them. The Administrator was asked for documentation related to the ongoing complaints about staffing and call light response from the resident council. The Administrator did not provide any documentation to demonstrate any efforts had been made by the facility to resolve the residents' grievances. The Administrator stated the staff were inserviced (educated) about answering call lights timely; however, she did not provide documentation of the inservice.	2020-09-01
660	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2018-03-14	600	D	1	0	2X2811	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on facility policy review, medical record review, facility investigation, and interview the facility failed to ensure two residents (#2, #3) were free from abuse of 10 residents reviewed for abuse. The findings included: Review of the facility policy, Abuse Protocol, dated 11/2016, revealed .Each resident has the right to be free from abuse .2. Abuse means the willful infliction of injury . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed resident Brief Interview for Mental Status (BIMS) score of 10 indicating resident with moderately impaired cognition. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed resident Brief Interview for Mental Status (BIMS) score of 6 of 15 indicating resident with severe cognitive impairment. Review of a facility investigation dated 12/19/17 revealed .nurse notified of an altercation .upon entering room this nurse was told by CNA on staff that she had witnessed resident in bed #2 being hit by her mother. CNA on staff had separated the altercation .resident in bed #2 stated that resident in bed #1 had hit her in the face with a closed fist more than once .Resident in bed #1 stated resident in bed #2 mother stated to daughter be good, you need to stay here and proceeded to slap daughter. Resident in bed #2 proceeded to hit her mother. Resident in bed #2 stated she couldn't stand to see resident in bed #2 slap her mother, so she went over there and slapped resident in bed #2. Resident in bed #1 stated she got me, pulled my hair and bit my hand and when she did that I slapped the hell out of her . Review of facility investigation statements and interview with the Assistant Director of Nursing (ADON) on 3/13/18 at 9:51 AM, in the activity room, confirmed resident #2 had been smacked by her mother. Continued interview revealed resident #3's hair was pulled and her hand had been bitten by resident #2.	2020-09-01
661	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2018-03-14	725	E	1	0	2X2811	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on medical record review, observation, and interview, the facility failed to provide adequate nursing staff to meet the needs of 2 residents ( #5, #13) of 6 residents ( #1, 3, 5, 9, 12, and 13) sampled for quality of care and residents who attended the resident council meetings. The findings included: Medical record review of Resident #13 revealed she had [DIAGNOSES REDACTED]. Review of the admission nursing assessment, dated 3/3/18 revealed she did not show signs of cognitive loss or communication limitations; she required assistance with all her activities of daily living (ADLs). Her plan of care with an effective date of 3/5/18 stated she had an ADL self-care problem because she required assistance with ADLs. Observation on 3/13/18 at 5:45 AM revealed the facility had a census of 76 residents, and there were a total of two certified nurse aides, (CNA) #1 and CNA #2, and two licensed practical nurses, (LPN) #1 and LPN #6 in the facility. On 3/13/18 at 6:10 AM CNA #2 was interviewed in the hallway. She stated they were supposed to have three CNAs working; however, one called in and that left just her and another CNA to care for 76 residents. She stated the LPNs helped when they could; however, they were still unable to meet the needs of the residents timely when they only had two aides working. CNA #2 was asked if any of the residents experienced falls or were not able to make it to the bathroom on time due to not having the third CNA to help. CNA #2 stated Resident #13 was not assisted to the bathroom timely and had a bowel movement in her incontinence brief when she normally made it to the bathroom and voided on the toilet. Interview with Resident #13 in her room on 3/13/18 at 8:15 AM, revealed she had been in the facility for a little over a week, and she felt she could, get better care at home. She stated when she put her call light on it, takes forever to get help. She stated she put her call light on last night because she needed to have a bowel movement (BM) and waited 10 minutes in her bed and when no one came and she could not hold it any longer she got up by herself with her walker to go to the bathroom. She stated her doctor told her not to get up without help because of her blood pressure, but she had no choice. She stated, just as she stood up she had an accident and got (BM) on the floor and in her brief. She stated once she got into the bathroom, she put the call light on because she had BM up her back and she needed help to get cleaned up. She stated she had to wait 20 more minutes while sitting on the toilet in the bathroom before staff arrived. The resident stated she found it frustrating to have to wait. Medical record review of Resident #5's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed he had a Brief Interview for Mental Status score of 14/15 (indicating he was cognitively intact). Continued review revealed Resident #5 required extensive assistance of 2 staff for bed mobility and transfers. Interview with Resident on 3/12/18 at 3:44 PM, in his room, revealed the facility needed more staff on the third shift. He stated, It just seems like there were no staff in the building on night shift. When asked if his call light was answered timely, he stated it took a while for it to get answered, but did not state how long. Review of the Resident Council Meeting Minutes for (MONTH) (YEAR) through (MONTH) (YEAR) revealed residents voiced concerns every month related to the facility not having adequate staff to meet their needs and/or not having care needs met timely. Cross reference F565. Interviews were conducted on 3/14/18 at 9:48 AM with the Director of Nursing (DON) and the Administrator in the activity room. The DON stated the goal was to have 3 to 4 CNAs and 2 nurses on the 11:00 PM to 7:00 AM shift. She stated a CNA called in prior to the beginning of the 3/12/18, 11:00 PM to 7:00 AM shift and she attempted to get a replacement without any luck. She stated the 11:00 PM to 7:00 AM staff called her at home after the shift started and informed her that the CNA had not come to work. Continued interview confirmed she informed them of the call off and again attempted to call in a replacement without any success. The Administrator was informed of what Resident #13 had stated about taking 30 minutes to get her light answered, and CNA #2 confirmed the resident had bowel incontinence because she (CNA #2) was unable to answer her call light in a timely manner, the Administrator stated if the resident stated it took 30 minutes then it took 30 minutes. The Administrator stated, Then we can do better. She stated they experienced high turnover and were having a hard time recruiting staff, despite advertising on the radio and on social media sources. She stated they also had a difficult time getting employees to fill in for staff who called off, despite offering pay incentives to work overtime and pick up additional shifts.	2020-09-01
662	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2019-03-26	550	D	0	1	GERH11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview the facility failed to promote resident rights to respect and dignity, and ensure privacy for 1 resident (#8) of 1 resident reviewed of 19 sampled residents. The findings include: Review of the facility policy Dignity and Respect, dated 7/91, revealed .Residents' individual preferences .clothing .are elicited and respected by the facility .Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the Resident from passers-by . Review of the facility policy Activities of Daily Living, dated 3/17, revealed .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident was severely cognitively impaired. Further review revealed dressing required extensive assistance of 2 staff members. Medical record review of Resident #8's care plan, dated 12/26/18, revealed .Assist me with bed mobility, transfers, toileting, grooming, dressing, and locomotion . Observation and family interview with Resident #8's family on 3/24/19 at 12:45 PM, in the resident's room, revealed the resident was .left in hospital clothes, and never has pants on . The resident was dressed in a hospital gown, without pants, at the time of the interview. Observation and family interview with Resident #8's family on 3/25/19 at 4:57 PM, in the resident's room, revealed the resident remains in bed dressed in a hospital gown, and no pants.I wish they would put clothes on him every day .it would make him feel better, and stay warmer . Observation of Resident #8 on 3/26/19 at 8:31 AM, from the 100 hallway, revealed resident lying disheveled, and uncovered with his legs and brief exposed. Interview with the Director of Nursing (DON) on 3/26/19 at 8:54 AM, in the 100 hallway, revealed it would depend on the resident's preferences and needs as to what clothing she would expect them to have on. Continued interview confirmed, .honestly, it is easier to provide care to some of them in a gown .if people are up and going to therapy, they need shirt and pants on . Interview with the DON on 3/26/19 at 9:10 AM, in the conference room, confirmed the facility failed to promote resident rights to respect and dignity, and to ensure privacy for Resident #8.	2020-09-01
663	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2019-03-26	812	F	0	1	GERH11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation, and interview, the facility failed to discard expired and damaged food items and failed to ensure food items were not open to air in 2 of 3 coolers, 1 of 1 bread racks, and 1 of 1 freezers. The findings include: Review of the facility policy Food Storage dated [DATE], revealed .Food is stored and prepared in clean safe sanitary manner that will comply with state and federal guidelines . Observation of the kitchen with Dietary Aide #1 on [DATE] at 9:43 AM, revealed the following: In the upright cooler: (5) cartons of 2% (percent) milk with a use by date of [DATE] In the milk cooler: (13) cartons of 2% (percent) milk with a use by date of [DATE] On the bread rack: (3) packages of 12 count hotdog buns with a use by date [DATE] (6) 1lb (pound) loaves of whole wheat bread with a use by date of [DATE] (2) 1lb loaves of sandwich bread with a use by date of [DATE] (1) 1lb sandwich bread with the bread damaged and open to air with a hole in the bottom of the bag (5) slices left in a 1lb bag of wheat bread with a use by date of [DATE] In the walk-in freezer: (2) frozen burger patties in a box open to air (1) 20 lb box of frozen peas open to air (20) frozen biscuits in a box open to air Interview with the Dietary Director on [DATE] at 10:30 AM, in the kitchen, confirmed the facility failed to ensure expired food items were not available for resident use, failed to ensure damaged foods were not available for resident use, and failed to ensure foods were not stored open to air.	2020-09-01
664	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2018-05-02	657	D	0	1	Y2B811	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and interview, the facility failed to revise the care plan for 1 resident (#71) of 18 sampled residents. The findings included: Medical record review revealed Resident # 71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility policy Fall Prevention Program, revised 3/17 revealed, .When a fall occurs .These interventions will be documented in the medical record as well as the Kardex (medical information system used to communicate information about patients) /CNA (certified nursing assistant) Communication Sheet Review of facility's Incident Case Report dated 4/10/18 with completion date of 5/1/18 revealed, . new action is to use the bedpan opposed to bedside commode . Medical record review of the care plan dated 4/10/18 revealed no intervention for use of a bed pan. Medical record review of Post Incident Documentation, dated 4/14/18, revealed, . new interventions put in place? Yes .New intervention added to Care Plan / Kardex? Yes . Review of Resident #71's current KARDEX revealed, no intervention for use of bedpan , further review revealed, .Fall interventions: Non-skid socks. Interview with CNA # 1 on 5/02/18 at 7:44 AM, in the station 3 hallway, confirmed Resident #71 used bedside commode (BSC) for toileting. Interview with the Director of Nursing (DON) on 5/02/18 at 10:52 AM, in the DON's office, confirmed the facility failed to revise the care plan for Resident #71 following a fall.	2020-09-01
665	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2018-05-02	689	D	0	1	Y2B811	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, review of facility investigation, medical record review, observation, and interview, the facility failed to implement a new intervention and monitor effectiveness of interventions after a fall for 1 resident (#71) of 4 residents reviewed for falls of 18 sampled residents. The findings included: Review of the facility policy Fall Prevention Program, revised 3/17 revealed, .When a fall occurs .These interventions will be documented in the medical record as well as the Kardex (medical information system used to communicate information about patients) /CNA (certified nursing assistant) Communication Sheet For 72 hours following the fall, staff will document .The resident's reaction/response to the new fall intervention placed . Medical record review revealed Resident # 71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record Review of Admission Minimum Data Set (MDS), dated [DATE], revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident required staff assistance for transfers and toileting. Medical Record Review of progress notes dated 4/14/18 revealed, This nurse was approached by CNA and told that resident had fallen in the floor . Review of facility's Incident Case Report dated 4/10/18 (correct date 4/14/18) revealed, . new action is to use the bedpan opposed to bedside commode . Medical record review of Post Incident Documentation, dated 4/14/18, revealed, . new interventions put in place? Yes .New intervention added to Care Plan / Kardex? Yes . Medical record review of the care plan dated 4/10/18 revealed no intervention for use of a bedpan. Review of Resident #71's current KARDEX (not dated) revealed no intervention for the use of a bedpan. Further review revealed, .Fall interventions: Non-skid socks . Observation of Resident # 71 on 5/01/18 at 7:56 AM, in the resident's room, revealed the resident lying in bed with a bedside commode (BSC) and safety mat at the bedside. Observation of Resident #71 on 5/02/18 at 7:33 AM, in the resident's room, revealed a BSC and safety mat in place at the bedside. Interview with CNA #1 on 5/02/18 at 7:44 AM, in the station 3 hallway, confirmed Resident #71 uses a BSC for toileting. Interview with the Director of Nursing (DON) on 5/02/18 at 8:27 AM, in the DON's office, confirmed Resident #71's fall occurred on 4/14/18 and the Incident Case Report date of 4/10/18 was incorrect. Further interview confirmed after falls occur, the resident would be assessed, the DON would be called to assist with new interventions and staff would complete a report. Continued interview confirmed the Interdisciplinary Team would review the interventions the following day to ensure the new intervention was appropriate. Further interview confirmed the facility would monitor the effectiveness and resident's response of the new intervention for 3 days after a fall, and review/revise as needed. Continued interview confirmed the new interventions would be added to the Kardex and the care plan would be updated. Interview with Resident #71 on 5/02/18 at 9:38 AM, in the resident's room, confirmed Resident #71 used BSC or bathroom for toileting and stated, .I hate a bedpan . Interview with the DON on 5/02/18 at 10:52 AM, in the DON's office, confirmed the facility failed to implement the new intervention and monitor effectiveness following Resident #71's fall.	2020-09-01
666	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2018-05-02	791	D	0	1	Y2B811	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview the facility failed to ensure dental services were provided for 1 resident (#17) of 18 sampled residents. The findings included: Review of the facility policy Dental Services - Professional, revised 3/17 revealed, .routine and emergency dental services are available to meet the resident's oral health .nursing services is responsible for notifying Social Services of a resident's need for dental services .Social Services personnel will be responsible for assisting the resident/family in making dental appointments . Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed .Obvious or likely cavity or broken natural teeth . Observation of Resident #17 on 4/30/18 at 10:34 AM, in the resident's room revealed the resident with tooth decay. Interview with the Director of Social Services on 5/2/18 at 8:20 AM, in the Social Services Office, confirmed Resident #17 had tooth decay and was scheduled to be seen by dental services on 4/20/18. Further interview confirmed Resident #17 was not seen by dental services on 4/20/18 despite being scheduled. Continued interview confirmed the facility failed to provide dental services for Resident #17 since admission to the facility on [DATE].	2020-09-01
667	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2018-05-02	880	D	0	1	Y2B811	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to post an isolation precaution sign on the door of 1 Resident (#328) of 3 residents on isolation precautions of 18 residents sampled of 73 total residents. The findings included: Review of the facility policy Reverse Isolation revised 11/17 revealed, .Place 'Please see nurse before entering room' sign on the outer door . Medical record review revealed Resident #328 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician order dated 4/25/18 revealed, .reverse isolation (isolation procedures designed to protect a patient from infectious organisms that might be carried by the staff, other patients, or visitors) for [DIAGNOSES REDACTED] (an abnormally low count of a type of white blood cell) . Medical record review of the care plan dated 4/25/18 revealed, .I am in reverse isolation because my immune system is low and I am susceptible to bacteria/viruses .Post signs at my door informing visitors to check in with licensed staff prior to entering room . Observation during initial tour of Resident #328's room, on 4/30/18 at 9:45 AM, in the station 3 hallway, revealed no isolation precaution sign on the door. Interview with Certified Nurses Aid (CNA) #2, on 4/30/18 at 9:45 AM, in the station 3 hallway, revealed Resident #328 was on reverse isolation precautions and a mask needed to be worn when entering the resident's room for his protection. Interview with the Registered Nurse Consultant, on 4/30/18 at 10:06 AM, in the Station 3 hallway, confirmed Resident #328 was on reverse isolation precautions and the facilty failed to post a sign on the resident's door to notify staff and visitors of the reverse isolation.	2020-09-01
4010	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2016-12-22	204	D	1	0	C3FJ11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on medical record review and interview, it was determined the facility failed to provide sufficient discharge preparation for home health services for one Resident (#1) of five Residents reviewed. The findings included: Medical record review of a Record of Admission and a Client [DIAGNOSES REDACTED].#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's Brief Interview for Mental Status (BIMS) score was 15 on a scale of zero-to-15, with 15 being the highest score achievable to indicate an intact cognition. Continued review revealed the Resident required limited assistance with all Activities of Daily Living (ADLs) except eating and bathing; and Resident #1 was independent with eating and required extensive assistance with bathing. Further review of the MDS Assessment revealed the discharge from the facility was planned. Medical record review of an Interdisciplinary Progress Note dated 10/31/2016, at 10:54 AM, and completed by the Director of Social Services (DSS), revealed, .Resident is requesting to be discharged home today . Medical record review of a Physician's Telephone Order dated 10/31/2016, at 4:49 PM, revealed, Discharge home with home health .skilled nsg (nursing) . Continued review of the Interdisciplinary Progress Notes on 10/31/2016, at 4:50 PM, revealed, .Resident discharged home . Medical record review revealed no documentation a home health provider was notified to arrange skilled nursing services, prior to, or on the day of, the Resident's discharge on 10/31/2016. Medical record review of a prescription pad sheet with an order dated 11/1/2016 and signed by the facility's Nurse Practitioner revealed, .(Home Health Provider) to begin services 11/2/16 d/t (due to) change in provider services for HH (Home Health) . Interview with the DSS on 12/14/2016 at 4:26 PM, in the Conference Room, revealed the DSS coordinated planned discharges and included arranging home health services for post-discharge care, as ordered. Further interview revealed the DSS stated, .Most people d/c'd (discharged ) to home from here need home health .it's rare that they don't . Telephone interview with the Care Transition Coordinator with Home Health Provider (HHP) #1 on 12/14/2016 at 6:50 PM, revealed the HHP (#1) had provided services for Resident #1 in the past. Continued interview confirmed the facility's DSS did not notify HHP #1 until 11/1/2016 (the day after Resident #1 was discharged from the facility). Continued interview confirmed HHP #1 declined to provide home health services for Resident #1 and recommended the facility notify another HHP. A second interview with the DSS on 12/14/2016 at 7:00 PM, in the Conference Room revealed the DSS stated, (HHP #1) had seen (Resident #1) in the past, I assumed they would again .so I called them (HHP #1) on 11/1/2016 .they refused to provide home health to (Resident #1) .recommended I call another home health (provider) . Continued interview revealed the DSS notified HHP #2 on 11/1/2016 and HHP #2 services were initiated on 11/2/2016, as ordered. Further interview confirmed the DSS was made aware of the intended discharge on the morning of 10/31/2016 at 10:54 AM, but failed to ensure home health services were arranged prior to Resident #1's discharge on 10/31/2016 at 4:50 PM (approximately six hours later). Telephone interview with Registered Nurse #1 with HHP #2 on 12/14/2016 at 8:00 PM confirmed Resident #1's start of care date for home health services was 11/2/2016 (two days after discharge from the facility). Continued interview confirmed the Resident was discharged from home health services on 11/18/2016. Interview with the Administrator on 12/14/2016 at 9:27 PM, in the Conference Room, confirmed the facility failed to ensure sufficient preparation and arrange home health services prior to the Resident's discharge on 10/31/2016.	2019-11-01
4011	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2016-12-22	309	D	1	0	C3FJ11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY > Based on medical record review and interview, it was determined the facility failed to provide sufficient discharge preparation for home health services and an antibiotic was not administered as ordered for one Resident (#1) of five Residents reviewed. The findings included: Medical record review of a Record of Admission and a Client [DIAGNOSES REDACTED].#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Summary and Skilled-Long Term Care Orders dated 10/26/2016 revealed Resident #1 was admitted to the hospital on [DATE] with [MEDICAL CONDITION] secondary to her right lower extremity wounds. Intravenous (IV) antibiotics were started on 10/22/2016 and administered through a Midline IV Catheter. Infectious Disease (ID) was involved in Resident #1's care due to the resistant bacteria in her leg wound and recommended treatment with [MEDICATION NAME] for a period of two weeks. Continued review revealed, Resident #1 received the 10/26/2016 dose of [MEDICATION NAME] prior to discharge. Further review revealed, upon discharge from the hospital to the facility, Resident #1 needed an additional 10 days of [MEDICATION NAME]. Medical record review of a Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the discharge from the facility was planned. Medical record review of a Physician's Telephone Order dated 10/26/2016 revealed an order for [REDACTED]. Medical record review of an Interdisciplinary Progress Note dated 10/31/2016, at 10:54 AM, and completed by the Director of Social Services (DSS), revealed, .Resident is requesting to be discharged home today . Medical record review of a Physician's Telephone Order dated 10/31/2016, at 4:49 PM, revealed, Discharge home with home health .skilled nsg (nursing) . Continued review of the Interdisciplinary Progress Notes on 10/31/2016, at 4:50 PM, revealed, .Resident discharged home . Medical record review of an Interdisciplinary Progress Note dated 10/31/2016 at 4:50 PM, revealed, : .Resident discharged home with son . Medical record review of a prescription pad sheet with an order dated 11/1/2016 and signed by the facility's Nurse Practitioner revealed, .(Home Health Provider) (#2) to begin services 11/2/16 d/t (due to) change in provider services for HH (Home Health). Will need IV [MEDICATION NAME] 1 GM (gram) until 11/6/16 D/T (due to) missed dose today . Telephone interview with the Care Transition Coordinator with Home Health Provider (HHP) #1 on 12/14/2016 at 6:50 PM, revealed the HHP (#1) had provided services for Resident #1 in the past. Continued interview revealed HHP #1's business hours of operation are Monday through Friday from 8:00 AM, to 5:00 PM. Further interview confirmed the facility's DSS did not notify HHP #1 until 11/1/2016, which was the day after Resident #1 was discharged from the facility. Continued interview confirmed HHP #1 declined to provide home health services for Resident #1 and recommended the facility notify another HHP. Interview with the DSS on 12/14/2016 at 7:00 PM, in the Conference Room revealed the DSS stated, (HHP #1) had seen (Resident #1) in the past, I assumed they would again .so I called them (HHP #1) on 11/1/2016 .they refused to provide home health to (Resident #1) .recommended I call another home health (provider) . Continued interview revealed the DSS notified HHP #2 on 11/1/2016 and HHP #2's services were not initiated until the next day on 11/2/2016. Further interview confirmed the DSS was notified by Resident #1 on the morning of 10/31/2016 (at 10:54 AM), but the DSS failed to ensure home health services were arranged prior to Resident #1's discharge on 10/31/2016. Telephone interview with Registered Nurse #1 with HHP #2 on 12/14/2016 at 8:00 PM confirmed Resident #1's start of care date for home health services, including the IV [MEDICATION NAME], was 11/2/2016. Continued interview confirmed the Resident was discharged from home health services on 11/18/2016. Telephone interview with the facility's Nurse Practitioner on 12/14/2016 at 8:55 PM, confirmed the administration of the IV [MEDICATION NAME] was necessary to treat the Resident's infection and should not have been missed on 11/ . Continued interview confirmed the order for the [MEDICATION NAME] was extended from 11/5/2016 to 11/6/2016 due to the missed dose. Interview with the Administrator on 12/14/2016 at 9:27 PM, in the Conference Room, confirmed the facility failed to ensure timely arrangements for home health services prior to the Resident #1's discharge on 10/31/2016. Continued interview confirmed the facilities failure resulted in the [MEDICATION NAME] not being administered on 11/1/2016, as ordered.	2019-11-01
6643	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2015-01-14	224	G	0	1	WY5111	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility investigation, review of the facility policy, and interview, the facility failed to protect from abuse one resident (#87) of five residents reviewed for abuse, of thirty-three residents reviewed, resulting in psychological harm to resident #87. The findings included: Resident #87 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of the Discharge Minimum Data Set (MDS) dated [DATE], and the Annual MDS dated [DATE], revealed the resident had moderately impaired cognitive skills for daily decision making. Review of a facility investigation dated December 2, 2014, revealed .Date of Occurrence: 12/2/14 .Resident reported to RN (Registered Nurse)(Assessment) Nurse that (resident) was afraid of the 'short, fat, blonde nurse.' (Resident) stated the 'nurse' fussed (at) (resident). The RN (Assessment) Nurse then asked a CNA (Certified Nursing Assistant) to assist (resident) (with) care. The RN (Assessment) Nurse overheard the CNA making rude comments to the resident (and) talking 'short' to the resident .Summary of interview with resident: The resident reported the CNA (named) has threatened (resident), poked (resident) in the back with .finger, told (resident) .wishes (resident) would die (and) told (resident) .doesn't like (resident) .Summary of investigator's findings: Investigation reveals RN Assessment Nurse heard CNA being verbally abusive to resident by stating 'You have made a mess,' and 'you are going to be up in your w/c (wheelchair) all night.' . Review of the statement obtained by the facility from RN Assessment Nurse #1 dated December 2, 2014, revealed .Overheard (resident #87) calling out. Went into room and there was odor of BM (Bowel Movement) .When I informed (resident #87) that I would get some help (resident #87) stated 'Don't get the short/fat one.' (Resident #87) could not tell me the name of the person (the resident) was afraid of. The CNA on the hall was informed of (resident #87) need .When informed (CNA #1) stated 'It shouldn't have to be this way.' (CNA #1) entered the room. I waited outside the door. The CNA was short with the resident .asked (resident) why .was playing 'in it'. I was unable to hear (resident #87) reply .(CNA #1) made other statements such as 'get your foot out of it' and 'You've made a mess of the floor mat.' .At one time it sounded like (CNA #1) told (resident) .was going to be up in .wc all night . Medical record review of the Social Service Progress Notes dated December 2, 2014, revealed .This writer spoke to resident to review concern that resident had with staff member. Resident .stated .preferred that staff person to not work with (resident #87) again . Review of a statement written by CNA #1 on December 5, 2014, revealed the CNA denied any physical or verbal abuse toward the resident. Further review revealed, after completing all care for resident #87, .When I came out of the room (staff member) was standing there and we spoke .I went on to the next person that's when (Assistant Director of Nursing/ADON) told me that they needed to speak to me when I finished. After finishing I went up the hall and (ADON) called me into the office where (Administrator, DON (Director of Nursing), ADON) were. (Administrator) informed that (resident #87) had stated that (resident) was afraid of me. That I was suspended upon completing an investigation . Review of the resident's statement obtained by the facility from the DON dated December 5, 2014, revealed .Spoke with resident .on 12/3/2014 regarding concern from 12/2/14. Resident states that CNA (named CNA #1) is mean .pokes (resident) in the back .tells (resident) .doesn't like her and fusses at (resident) when (CNA #1) has to clean (resident) up . Medical record review of a Psychiatric Progress Note dated December 8, 2014, revealed .(Patient) readily recalled events with CNA whom (resident) feared, and events were consistent with what (resident) told staff . Review of the facility policy, Abuse Protocol, last reviewed April 2014, revealed .The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion .Verbal abuse is any use of oral, written or gestured language that is made to Residents directly or within their hearing range, including disparaging or derogatory remarks regardless of their age, ability to comprehend, or disability .Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a Resident .Protection .Intervene immediately when you see abuse or neglect, even when you just suspect it, by telling the perpetrator to stop .they should immediately be separated from the Resident . Interview on January 12, 2015, at 4:00 p.m., with RN Assessment Nurse #1, in the conference room, confirmed the resident's call light was on and, when RN Assessment Nurse #1 went into the room, the resident stated had a bowel movement. The RN Assessment Nurse #1 sent CNA #1 in to clean the resident. RN Assessment Nurse #1 overheard CNA #1 being short with the resident. Continued interview with RN Assessment Nurse #1 confirmed CNA #1 was the CNA as described by the resident, but did not consider it abusive, more .tone, and the RN Assessment Nurse #1 reported CNA #1 immediately to the Administrator. Interview on January 13, 2015, at 8:35 a.m., with RN Assessment Nurse #1, in the conference room, confirmed RN Assessment Nurse #1 stayed outside of the resident's room when CNA #1 entered the room because of the comments resident #87 had made. Interview on January 13, 2015, at 9:00 a.m., with the DON, in the conference room, confirmed the resident was able to tell the DON the CNA's name when interviewed, and confirmed the facility failed to protect the resident from verbal abuse when the resident made an accusation of abuse, the accused CNA was sent into the resident's room, and the RN did not intervene. c/o #	2018-05-01
6644	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2015-01-14	226	G	0	1	WY5111	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility investigation, review of the facility policy, and interview, the facility failed to investigate an injury of unkown origin for one resident (#11) and failed to follow the abuse policy for one resident (#87) of five residents reviewed for abuse, of thirty-three residents reviewed, resulting in physical harm to resident #11 and psychological harm to resident #87. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review revealed the resident had [MEDICAL CONDITION] Disease and contractures to all four extremities. Medical record review of a nurse's note dated October 7, 2014, at 5:00 p.m., revealed .R (right) ext (extremity) swollen upper knee swollen .upon palpation to right extremity resident with moaning and facial grimacing-NP (nurse practitioner) notified-NO (new order) .to obtain X-Ray (R) knee and (R) femur . Medical record review of a Radiology Interpretation dated October 7, 2014, revealed .Right Hip .findings: a comminuted fracture (a fracture in which the bone is broken in several places or is shattered, creating numerous fragments) is present in the femoral neck and intratrochanteric region .There is a displacement of the greater trochanter . Review of an Orthopedic consult dated October 7, 2014, revealed, .nursing home resident with (R) intertrochanteric [MEDICAL CONDITION]. non-ambulatory previously. She does have bilateral lower and upper extremity contractures .unsure of mechanism of injury . Interview on January 13, 2015, at 2:48 p.m., with Licensed practical nurse (LPN) #3, in the conference room, revealed the LPN was notified of the change in resident condition by the resident's son at 5:00 p.m., on October 7, 2014. Continued interview revealed the LPN did not notice any changes on the prior assessments completed at 10:00 a.m., and 2:00 p.m. Interview and medical record review with the facility Medical Director on January 14, 2015, at 2:02 p.m., in the bookkeeping office, revealed the resident was at increased risk for a fracture due to age and medication use (no specific medication given), and a fracture could have occurred when the resident was repositioned or moved. Review of the facility policy Abuse Protocol, last reviewed April 2014, revealed .The facility will attempt to identify and proactively correct situations in which abuse is possible . Interview and review with the Administrator and Regional Nurse Consultant on January 14, 2015, at 2:25 p.m., in the bookkeeping office, confirmed the injury was not investigated as an injury of unknown origin. Resident #87 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Review of a facility investigation dated December 2, 2014, revealed .Date of Occurrence: 12/2/14 .Resident reported to RN (Registered Nurse)(Assessment) Nurse that (resident) was afraid of the 'short, fat, blonde nurse.' (Resident) stated the 'nurse' fussed (at) (resident). The RN (Assessment) Nurse then asked a CNA (Certified Nursing Assistant) to assist (resident) (with) care. The RN (Assessment) Nurse overheard the CNA making rude comments to the resident (and) talking 'short' to the resident .Summary of interview with resident: The resident reported the CNA (named) has threatened (resident), poked (resident) in the back with .finger, told (resident) .wishes (resident) would die (and) told (resident) .doesn't like (resident) .Summary of investigator's findings: Investigation reveals RN Assessment Nurse heard CNA being verbally abusive to resident by stating 'You have made a mess,' and 'you are going to be up in your w/c (wheelchair) all night.' . Review of the resident's statement obtained by the facility from the Director of Nursing (DON) dated December 5, 2014, revealed .Spoke with resident .on 12/3/2014 regarding concern from 12/2/14. Resident states that CNA (named CNA #1) is mean .pokes (resident) in the back .tells (resident) .doesn't like her and fusses at (resident) when (CNA #1) has to clean (resident) up . Medical record review of a Psychiatric Progress Note dated December 8, 2014, revealed .(Patient) readily recalled events with CNA whom (resident) feared, and events were consistent with what (resident) told staff . Review of the facility policy, Abuse Protocol, last reviewed April 2014, revealed .The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion .Verbal abuse is any use of oral, written or gestured language that is made to Residents directly or within their hearing range, including disparaging or derogatory remarks regardless of their age, ability to comprehend, or disability .Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a Resident .Protection .Intervene immediately when you see abuse or neglect, even when you just suspect it, by telling the perpetrator to stop .they should immediately be separated from the Resident . Interview on January 13, 2015, at 9:00 a.m., with the DON, in the conference room, confirmed the resident was able to tell the DON the CNA's name when interviewed, and confirmed the abuse policy was not followed when the resident made an accusation of abuse, the CNA was sent into the resident's room, and the RN did not intervene when overhearing the conversation. Refer to F224 c/o # and #	2018-05-01
6645	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2015-01-14	282	G	0	1	WY5111	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to follow the care plan for one resident (#11) of four residents reviewed for accidents, of thirty-three residents reviewed, resulting in physical harm to resident #11. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was severely cognitively impaired and required total assistance of two or more staff persons for bed mobility and transfers. Medical record review of the resident's Care Plan dated August 29, 2014, revealed, .Problem .(resident) continues to be at risk for falls d/t (due to) poor safety awareness .Goal .decrease risk for falls related injuries .transfer and mobility with 2 staff . Medical record review of a Status Change dated October 4, 2014, revealed .called to room by CNA (certified nursing aide) pt (patient) fell OOB (out of bed). Observed patient lying on right side, agitated, with blood on floor underneath .head called 911 . Medical record review of a Physician telephone order dated October 4, 2014, revealed .Send to .(hospital) for eval (evaluation) and treatment 2 (secondary) fall with laceration . Medical record review of a hospital emergency report dated October 4, 2014, revealed, .mechanism of injury .rolled out of bed at NH (nursing home) .laceration location .behind right ear, 0.5 cm (centimeters) .MD (medical doctor) at bedside .laceration secured with surgiseal . Medical record review of a nurse's note dated October 4, 2014, at 5:00 p.m., revealed resident returned to facility .from ER (emergency room ) resident sent to ER secondary to fall from bed with laceration at 2:30 p.m . Review of the POS [REDACTED]. Telephone interview with CNA #5 on January 14, 2015, at 11:06 a.m., revealed the CNA was providing incontinence care to the resident in the resident's room, rolled the resident on the resident's side, turned away from the resident to pull the privacy curtain, and the resident fell from the bed while the CNA was turned around. Further interview confirmed the CNA did not have another staff member present during care. Interview and review of the facility investigation with Regional Nurse Consultant #1 on January 14, 2015, at 2:04 p.m., in the bookkeeping office, revealed .CNA providing peri-care turned head away to pull privacy curtain, felt resident against legs, attempted to catch resident but slid to floor . Continued review and interview confirmed there was not two staff members providing care as required by the MDS and care plan, and the fall on October 4, 2014, resulted in harm (a [MEDICAL CONDITION] requiring medical intervention) to resident #11. c/o: #	2018-05-01
6646	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2015-01-14	323	G	0	1	WY5111	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, facility policy review, and interview, the facility failed to prevent an accident during care for one resident (#11) of four residents reviewed for accidents, of thirty-three residents reviewed, resulting in harm to resident #11. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was severely cognitively impaired and required total assistance of two or more staff persons for bed mobility and transfers. Medical record review of the resident's Care Plan dated August 29, 2014, revealed, .Problem .(resident) continues to be at risk for falls d/t (due to) poor safety awareness .Goal .decrease risk for falls related injuries .transfer and mobility with 2 staff . Medical record review of a Status Change dated October 4, 2014, revealed .called to room by CNA (certified nursing aide) pt (patient) fell OOB (out of bed). Observed patient lying on right side, agitated, with blood on floor underneath .head called 911 . Medical record review of a Physician telephone order dated October 4, 2014, revealed .Send to .(hospital) for eval (evaluation) and treatment 2 (secondary) fall with laceration . Medical record review of a hospital emergency report dated October 4, 2014, revealed, .mechanism of injury .rolled out of bed at NH (nursing home) .laceration location .behind right ear, 0.5 cm (centimeters) .MD (medical doctor) at bedside .laceration secured with surgiseal . Medical record review of a nurse's note dated October 4, 2014, at 5:00 p.m., revealed resident returned to facility .from ER (emergency room ) resident sent to ER secondary to fall from bed with laceration at 2:30 p.m . Review of the facility policy Fall Prevention Program, revised July 2014, revealed .The Fall Prevention Program is designed to ensure a safe environment for all Residents .Anticipate needs by assessing normal routines and times of increased risk . Telephone interview with CNA #5 on January 14, 2015, at 11:06 a.m., revealed the CNA was providing incontinence care to the resident in the resident's room, rolled the resident on the resident's side, turned away from the resident to pull the privacy curtain, and the resident fell from the bed while the CNA was turned around. Interview and review of the facility investigation with Regional Nurse Consultant #1 on January 14, 2015, at 2:04 p.m., in the bookkeeping office, revealed .CNA providing peri-care turned head away to pull privacy curtain, felt resident against legs, attempted to catch resident but slid to floor . Continued interview confirmed the facility failed to prevent the fall on October 4, 2014, resulting in harm (a head laceration requiring medical intervention) to resident #11. c/o: #	2018-05-01
6647	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2015-01-14	490	G	0	1	WY5111	Based on medical record review, review of facility investigation, review of the facility policy, and interview, the facility failed to provide effective adminstration to protect from abuse one resident (#87) of five residents reviewed for abuse, of thirty-three residents reviewed, resulting in psychological harm to resident #87. The findings included: Review of a facility investigation dated December 2, 2014, revealed .Date of Occurrence: 12/2/14 .Resident reported to RN (Registered Nurse)(Assessment) Nurse that (resident) was afraid of the 'short, fat, blonde nurse.' (Resident) stated the 'nurse' fussed (at) (resident). The RN (Assessment) Nurse then asked a CNA (Certified Nursing Assistant) to assist (resident) (with) care. The RN (Assessment) Nurse overheard the CNA making rude comments to the resident (and) talking 'short' to the resident .Summary of interview with resident: The resident reported the CNA (named) has threatened (resident), poked (resident) in the back with .finger, told (resident) .wishes (resident) would die (and) told (resident) .doesn't like (resident) .Summary of investigator's findings: Investigation reveals RN Assessment Nurse heard CNA being verbally abusive to resident by stating 'You have made a mess,' and 'you are going to be up in your w/c (wheelchair) all night.' . Review of the statement obtained by the facility from RN Assessment Nurse #1 dated December 2, 2014, revealed .Overheard (resident #87) calling out. Went into room and there was odor of BM (Bowel Movement) .When I informed (resident #87) that I would get some help (resident #87) stated 'Don't get the short/fat one.' (Resident #87) could not tell me the name of the person (the resident) was afraid of. The CNA on the hall was informed of (resident #87) need .When informed (CNA #1) stated 'It shouldn't have to be this way.' (CNA #1) entered the room. I waited outside the door. The CNA was short with the resident .asked (resident) why .was playing 'in it'. I was unable to hear (resident #87) reply .(CNA #1) made other statements such as 'get your foot out of it' and 'You've made a mess of the floor mat.' .At one time it sounded like (CNA #1) told (resident) .was going to be up in .wc all night . Review of a statement written by CNA #1 on December 5, 2014, revealed the CNA denied any physical or verbal abuse toward the resident. Further review revealed, after completing all care for resident #87, .When I came out of the room (staff member) was standing there and we spoke .I went on to the next person that's when (Assistant Director of Nursing/ADON) told me that they needed to speak to me when I finished. After finishing I went up the hall and (ADON) called me into the office where (Administrator, DON (Director of Nursing), ADON) were. (Administrator) informed that (resident #87) had stated that (resident) was afraid of me. That I was suspended upon completing an investigation . Medical record review of a Psychiatric Progress Note dated December 8, 2014, revealed .(Patient) readily recalled events with CNA whom (resident) feared, and events were consistent with what (resident) told staff . Review of the facility policy, Abuse Protocol, last reviewed April 2014, revealed .The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion .Verbal abuse is any use of oral, written or gestured language that is made to Residents directly or within their hearing range, including disparaging or derogatory remarks regardless of their age, ability to comprehend, or disability .Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a Resident .Protection .Intervene immediately when you see abuse or neglect, even when you just suspect it, by telling the perpetrator to stop .they should immediately be separated from the Resident . Interview on January 13, 2015, at 8:35 a.m., with RN Assessment Nurse #1, in the conference room, confirmed RN Assessment Nurse #1 stayed outside of the resident's room when CNA #1 entered the room because of the comments resident #87 had made. Further interview confirmed the RN did not intervene at the time of the verbal abuse. Review of the facility investigation, statements of staff, and interviews confirmed the RN overheard CNA #1 verbally abusing resident #87, reported the abuse to the Administrator, and CNA #1 was not stopped immediately from providing care to resident #87, or other residents, by the RN Assessment Nurse, the DON, the ADON, or the Administrator. c/o #	2018-05-01
8771	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2013-12-04	323	D	0	1	IL8E11	Based on medical record review, observation, and interview, the facility failed to ensure one resident (#8) of four residents reviewed received adequate supervision and assistive devices to prevent accidents. The findings included: Medical record review of a Care Plan dated November 11, 2013, revealed . (Resident #8) is at risk for injuries/falls .Interventions .Status: Active .Bed Alarm . Medical record review of the Medication Record for December 1, 2013 through December 31, 2013, revealed Bed Alarm when in Bed. Observation of resident #8 with Licensed Practical Nurse (LPN) #1 on December 4, 2013, at 9:10 a.m., revealed the resident lying in bed, eating breakfast. Observation revealed the bed alarm control box secured behind the head board at the head of the bed without the lead wire connected to the box. Continued observation revealed the lead wire connection was laying between the mattress and the side rail and not connected to the alarm. Further observation revealed LPN #1 connected the lead wire to the control box. Observation revealed LPN #1 was not able to test the alarm due to the alarm being turned off. Interview with LPN #1 and the Director of Nursing in the Activity Room on December 4, 2013, at 9:20 a.m., confirmed the bed alarm was turned off with the lead wire disconnected from the control box. Continued interview confirmed the facility had failed to ensure the alarm was working appropriately to alert staff to unassisted tranfers. C/O #	2017-04-01
8772	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2013-12-04	371	F	0	1	IL8E11	Based on observation, facility policy review, and interview, the facility failed to maintain a clean and sanitary kitchen. The findings included: Observation on December 2, 2013, at 7:35 p.m., during the initial tour of the kitchen revealed: 1. Three of three muffin pans with black crusty debris on the inside and outside and one of three muffin pans had rust colored debris on the inside. 2. Five of six size 400 pans with black crusty debris on the inside and outside and three of the five pans had water droplets on the inside and outside. 3. Twenty of twenty-two size 200 pans were dirty with brown and black debris on the inside. 4. Two of two large deep pans (used to cook meat) with crusty brown and white debris on the inside. 5. Two of two shallow pans (used to cook meat) with crusty brown and white debris on the inside. 6. One of one large dessert pan with black and white debris on the inside. 7. Twenty of twenty-one sheet pans with white crusty debris on the inside. Continued observation in the kitchen at the food preparation area revealed: 1. Two of two stack convection ovens with black crusty debris and food particles on the inside at the bottom. 2. Five of six wells on the steam table had food debris and white particles floating in the water. One of the five wells also had hair floating in the water. 3. One of one free standing deep fryer containing black oil with food particles floating in the oil. Unable to visualize the bottom of the deep fryer due to the blackness of the oil. Also food debris on the outside of the fryer. Observation of the front serving area on December 3, 2013, at 7:15 a.m., revealed: 1. The ice tea maker had dark brown sticky areas in numerous areas on the outside of the dispenser. The dispenser was empty. 2. The Juice machine had orange dried sticky substance in numerous areas on the outside of the machine. Review of facility policies for cleaning and sanitizing revealed: 1. .Beverage Fountain .Properly Clean and Sanitize Post-Mix Beverage Machines Procedure Frequency: daily . 2. .Deep Fryer .Cleaning & Sanitizing .Procedure Frequency: Daily: Exterior Weekly: .When Needed 3. .Ice Tea Dispenser .Cleaning & Sanitizing .after each use . 4. .Oven: Bake/Stack .Degreasing & Cleaning .Frequency: weekly: 5. .Steam Table Cleaning & Sanitizing .Frequency: After each use . Interview with Dietary Cook #1 on December 2, 2013, in the kitchen during the initial tour and at the time of the first observation confirmed the facility had failed to maintain a clean and sanitary kitchen. Interview with the Dietary Manager on December 3, 2013, at 7:20 a.m., in the front serving area confirmed the ice tea maker had not been used since the day before (December 2, 2013). The Dietary Manager also confirmed the substances on the juice machine had not just occurred and the kitchen equipment was not clean and sanitary.	2017-04-01
8773	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2013-12-04	431	D	0	1	IL8E11	Based on observation, review of facility policy, and interview, the facility failed to ensure all medications were in date for one of three medication carts and in one of two medication rooms. The findings revealed: Observation with Licensed Practical Nurse (LPN) #1 on December 3, 2013, at 7:51 a.m., revealed the 100 hall medication cart contained an open bottle of Aspirin 325 mg (milligram) with an expiration date of December 2012. Observation with the Director of Nursing (DON) on December 3, 2013, at 8:35 a.m., in the 200 hall medication room revealed twelve Ondanestron (antiemetic medication) 4 mg tablets with an expiration date of November 30, 2013, and three Warfarin (blood thinner) 6 mg tablets with an expiration date of August 30, 2012. Review of facility policy, Medication Storage In The Facility, revealed .13. Outdated .medications .are immediately removed from stock, disposed of according to procedures for medication destruction . Interview with the DON on December 3, 2013, at 3:40 p.m., confirmed the facility had failed to dispose of all outdated medications.	2017-04-01
8774	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2013-12-04	441	D	0	1	IL8E11	Based on observation and interview, the facility failed to ensure infection control was maintained for one (#43) of six indwelling catheter drainage bags. The findings included: Observation on December 3, 2013, at 8:00 a.m., in the main dining room revealed resident #43 sitting in a geri chair with a covered indwelling catheter drainage bag lying on the floor underneath the seat. Interview with Registered Nurse (RN) #1 at the time of the observation confirmed the indwelling catheter drainage bag was on the floor and should not be there. Interview with the Director of Nursing (DON) on December 4, 2013, at 10:35 a.m., in the DON's office confirmed the facility had failed to maintain infection control by placing the indwelling catheter drainage bag on the floor.	2017-04-01
10530	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2013-06-04	282	D	1	0	WDL911	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, facility policy review, review of personnel files and interview, the facility failed to provide incontinence care for one (#8) of nine residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident scored 5/15 on the Brief Interview for Mental Status (BIMS) with severe cognitive impairment; required extensive assistance of two for bed mobility and transfers; required extensive assistance with dressing; was totally dependent on staff for hygiene and bathing; required assistance with moving from a seated to a standing position, moving on and off the toilet and surface-to-surface transfers; and was incontinent of bowel and bladder. Medical record review of the care plan updated August 15, 2012 revealed the resident was at risk for impaired skin integrity related to decreased mobility and bowel incontinence. Continued review revealed Provide incontinence care following incontinent episodes .[MEDICATION NAME] (multipurpose moisture barrier) PRN (as needed) to buttocks . Review of the personnel file (investigation for allegation of abuse) for Certified Nursing Assistant (CNA) #1 (terminated from the facility on November 6, 2012) revealed Licensed Practical Nurse (LPN) #1 documented a written warning dated August 31, 2012 at 9:30 p.m. for CNA #1. Continued review of the disciplinary action revealed (Resident #8) .so wet (with bowel movement (BM)) brief fell apart-skin gualded (red skin caused by wetness) .Full bed (symbol for change) .BM all over scrotum gualded (gaulded) . Continued review of the personnel file for CNA #1 revealed a second written warning was issued by LPN #2 on November 5, 2012 and noted .(Resident #8) was wet. Resident was not changed or position changed in 5 hrs. (hours) . Telephone interview on May 29, 2013 at 5:50 p.m. with LPN #1 confirmed CNA #1 and LPN #1 worked the evening shift on August 31, 2012 and confirmed CNA #1 was assigned to resident #8. Continued interview confirmed when LPN #1 checked (resident #8), the resident was so wet the brief fell apart and confirmed dried BM and gaulding on the scrotum. Continued interview revealed the LPN Stopped my treatments and my meds (medication pass) and confirmed me and the oncoming CNA (#3) provided incontinence care and a full bed change for the resident. Continued interview confirmed LPN #1 .knew rounds had not been done. There's a noticeable difference in just having changed someone and it (urine and feces) being there a long time. It was noticeable. Telephone interview on May 29, 2013 at 6:13 p.m. with CNA #3 (who relieved CNA #1 on August 31, 2012) confirmed It was evident .hadn't been changed for hours. Telephone interview on May 29, 2013 at 6:55 p.m. with LPN #2 confirmed LPN #2 documented the written warning (#2) for CNA #1 on November 5, 2012. LPN #2 confirmed CNA #1 worked the night shift (same shift as LPN #2) on November 5, 2013. LPN #2 stated, I marked the pad and the brief (for resident #8) .went back (after) five hours and they (pad and brief) had not been changed. (Resident) was wet. C/O #	2016-06-01
11267	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2012-07-16	157	G	0	1	CWKE11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility policy, observation, and interview, the facility failed to notify the physician of a pressure ulcer for one (#27) of forty residents reviewed. The facility's failure resulted in a delay of physician treatment and harm to resident #27. The findings included: Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set, dated dated dated [DATE], revealed the resident was at risk for developing pressure ulcers, had a stage 3 pressure ulcer (right heel), had a pressure reducing device for the bed, and required extensive assistance with bed mobility. Medical record review of the Wound/Skin Healing Record dated March 7, 2012, revealed, .pre-admit .stage III .Right heel .0.5 x 0.9 x (less than) 0.2 (centimeters) .wound bed brown (eschar) . Medical record review of the Wound/Skin Healing Record dated April 3, 2012, revealed, .(right heel) 0.4 x 0.7 x (less than) 0.2 (centimeters) .granulation tissue .slough .brown eschar . Review of the next Weekly Wound Report dated April 17, 2012, revealed .(right) lateral heel stage 3 0.4 x 0.7 (less than) 0.2 (centimeters) .loose eschar . Medical record review of a skin assessment dated [DATE], revealed, .small area of eschar to (right) heel .0.5 cm x 1 cm .no other skin breakdown noted . Medical record review of a skin assessment dated [DATE], revealed, .healing stage (2) Rt (right) heel Stage (2) coccyx-noted 7/4/12 Reddened area around coccyx .Pressure sores are to be measured weekly by skin assessment nurse . Medical record review revealed the next wound assessment dated [DATE], revealed, . eschar on (right heel) (1cm x 0.5 cm) 2 stage (2) wounds on coccyx ( .3 cm x 1.5 cm) ( .1.5 cm x 1 cm) Excoriated around wound bilat (bilateral) buttocks .Pressure sores are to be measured weekly by the skin assessment nurse . Medical record review of the care plan dated March 15, 2012, revealed .Perform complete skin assessment and record .1 time weekly starting 03/15/2012 . Review of the policy Stage III Pressure Ulcer, revealed, .Cleanse area with normal saline or wound cleanser .obtain physician order for [REDACTED].If indicated, Enzymatic debridement .to Necrotic area and apply [MEDICATION NAME] or saline moist loose gauze and cover dressing QD . Medical record review of the Treatment Records (dated March 7, 2012, through March 31, 2012,) and April 1, 2012, through July 31, 2012, revealed a treatment for [REDACTED]. Medical record review revealed no physician's order on admission or after for any treatment for [REDACTED]. Interview on July 11, 2012, at 10:40 a.m. with the DON, in the conference room, confirmed no physician's order had been obtained since the resident's admission on March 7, 2012, for treatment for [REDACTED]. Observation and interview on July 11, 2012, at 5:30 p.m. with the resident's physician revealed two stage 2 pressure ulcers on the coccyx and a pressure ulcer on the right heel with eschar, as described by the physician. Interview with the physician on July 11, 2012, at 5:30 p.m., in the resident's room, confirmed the physician was unable to recall being notified of the stage III pressure ulcer to the right heel.	2016-02-01
11268	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2012-07-16	221	D	0	1	CWKE11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the facility policy, observation, and interview, the facility failed to assess for the use of a restraint for two (#106, #27) residents of forty residents reviewed. The findings included: Resident #106 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident required extensive assistance with one person physical assist for bed mobility and transfers. Review of the facility policy, Restraints-Physical, revealed .A physical restraint is defined as any article, device, or garment that is used primarily to modify resident behavior by interfering with free movement .a physician's order is necessary for the use of a physical restraint .The need for restraints will be reevaluated at least quarterly to determine if continued restraint use is necessary to treat the resident's medical symptoms . Observation on July 12, 2012, at 7:40 a.m., with Licensed Practical Nurse (LPN) #2, revealed the resident lying in a low bed with 1/4 siderails up located in the center of the bed to keep the resident from exiting the bed. Observation on July 16, 2012, at 1:30 p.m., with the Director of Nursing (DON) revealed the resident lying in a low bed with 1/4 siderails in the mid bed position. Medical record review revealed no restraint assessment for the use of the siderails. Interview on July 16, 2012, at 12:55 p.m. with the DON, in the conference room, confirmed no assessment had been completed for the use of the siderails as a restraint. Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident required extensive assistance with two person physical assist for bed mobility and total dependence with two person physical assist for transfers, Observation on July 11, 2012, at 7:45 a.m. revealed the resident lying in a low bed with 1/4 siderails up located in the center of the bed to keep the resident from exiting the bed. Medical record review revealed no restraint assessment for the use of the siderails. Interview on July 11, 2012, at 9:45 a.m. with the Assistant Director of Nursing, in the conference room, confirmed no assessment had been completed for the use of the siderails as a restraint.	2016-02-01
11269	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2012-07-16	280	D	0	1	CWKE12	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to revise the care plan for three residents (#2, #9, and #14) of eighteen residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].may replace foley catheter if does not void before 7pm tonight . Medical record review of the current Interdisciplinary Care Plan last reviewed August 10, 2012, revealed no updates to reflect the indwelling catheter was discontinued on July 17, 2012. Interview with the Assistant Director of Nursing (ADON) on August 22, 2012, at 11:40 a.m., confirmed the Care Plan had not been revised to reflect the resident no longer had an indwelling uninary catheter. Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's recapitulation orders dated August 2012, revealed .change 20 Fr (French) Foley cath (catheter) prn (as needed) . Medical record review of the current Interdisciplinary Care Plan last reviewed August 14, 2012, revealed .foley cath change Q (every) month and PRN . Interview with the Assistant Director of Nursing (ADON) on August 22, 2012, at 11:40 a.m., confirmed the Care Plan had not been updated to reflect the resident's indwelling urinary catheter was to be changed as needed not every month. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's recapitulation orders dated August 2012, revealed .change foley cath prn . Medical record review of the current Interdisciplinary Care Plan last reviewed August 14, 2012, revealed .change foley cath 1 time monthly . Interview with the Assistant Director of Nursing (ADON) on August 22, 2012, at 11:40 a.m., confirmed the Care Plan had not been updated to reflect the resident's indwelling urinary catheter was to be changed as needed not every month.	2016-02-01
11270	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2012-07-16	281	D	0	1	CWKE11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medication record review, and interview, the facility failed to follow physician's orders for medication administration for one (#39) of forty sampled residents. The findings included: Resident #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed an initial psychiatric consult was obtained on May 11, 2012, for depression and medication management. Further review revealed the resident had been having increasingly paranoid thoughts. Further review revealed the resident was accusing staff of morbid acts such as killing the resident and taking out the resident's arteries. Medical record review revealed the resident was admitted to the hospital on May 18, 2012, and returned to the facility on [DATE]. Medical record review revealed a physician's order dated May 31, 2012, for [MEDICATION NAME] (antipsychotic medication) 20 mg.(milligrams) to be given daily at 5:00 p.m. Medical record review of the physician's signed recapituation (recap) orders for June 2012, revealed order for [MEDICATION NAME] 20 mg. to be given at 5:00 p.m., prn (as necessary). Review of the Medication Administration Record [REDACTED] Review of the Psychiatric Consultation Follow Up dated June 25, 2012, revealed the resident continued to have delusions and paranoia and the recommendation was to continue [MEDICATION NAME] 20 mg. daily at 5:00 p.m. Medical record review of the MAR for July 2012, revealed no documentation [MEDICATION NAME] 20 mg. was given on July 3 or 4, 2012. Interview with the Director of Nursing (DON) in the DON's office on July 11, 2012, at 2:45 p.m., confirmed the physician order sheet for June 2012, had been incorrectly transcribed and the resident was to have received [MEDICATION NAME] 20 mg. daily (not prn). Further interview confirmed the resident had not received [MEDICATION NAME] 20 mg. as ordered by the physician in June or July 2012.	2016-02-01
11271	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2012-07-16	282	D	0	1	CWKE11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to follow a care plan for indwelling catheter changes for one (#39) of forty residents reviewed. The findings included: Resident #39 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's Care Plan dated May 24, 2012, revealed intervention of change .catheter and drainage bag every thirty days and prn (as necessary). Medical record review of hospital documentation revealed the resident's catheter was changed while in the hospital on May 21, 2012, with orders to change monthly. Medical record review revealed no documentation of a catheter change since readmission (fifty-one days). Interview with the Director of Nursing (DON) in the DON's office on July 11, 2012, at 2:45 p.m., confirmed the resident's urinary catheter had not been changed since readmission on May 21, 2012.	2016-02-01
11272	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2012-07-16	309	D	0	1	CWKE11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to follow physician's orders for antipsychotic medication for one (#17) of forty residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had severe cognitive impairment and required assistance with all activities of daily living. Medical record review revealed the resident was placed on [MEDICATION NAME] (antipsychotic) 0.5 mg. (milligrams) twice daily on July 13, 2011. Medical record review revealed a physician's order dated June 26, 2012, to decrease [MEDICATION NAME] to 0.25 mg. every morning and 0.25 mg. at bedtime. Review of the Medication Administration Record [REDACTED]. Review of the physician's recapituation orders for July 2012, revealed an order for [REDACTED]. Interview with the Director of Nursing (DON) in the hallway on July 12, 2012, at 9:45 a.m., confirmed the medication order had been transcribed incorrectly on the physician's recap orders and the resident was to receive [MEDICATION NAME] 0.25 mg. at bedtime. Medical record review of the MAR for July, 2012, revealed no documentation [MEDICATION NAME] 0.25 mg. was given at bedtime on July 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or 11, 2012 (11 days). Observation on July 12, 2012, at 9:45 a.m., revealed the resident lying in bed with eyes closed. Interview with the DON in the hallway on July 12, 2012, at 9:45 a.m., confirmed the resident did not receive the bedtime dosage of [MEDICATION NAME] from June 26, through July 11, 2012, and no [MEDICATION NAME] 0.25 mg. morning dose was administered on June 27 - 30, 2012.	2016-02-01
11273	AGAPE NURSING AND REHABILIATION CENTER, LLC	445162	505 N ROAN STREET	JOHNSON CITY	TN	37604	2012-07-16	314	G	0	1	CWKE11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility policy, review of the Dietician Contract, observation, and interview, the facility failed to complete skin assessments, implement dietary recommendations, obtain physician orders for wound treatments, ensure the Registered Dietician assessed the resident, and ensure measures were in place to reduce pressure for resident #27. The facility also failed to ensure skin assessments were completed for resident #107. The facility's failure resulted in delayed treatments and harm to resident #27. The findings included: Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set, dated dated dated [DATE], revealed the resident was at risk for developing pressure ulcers, had a stage 3 pressure ulcer (right heel), had a pressure reducing device for the bed, and required extensive assistance with bed mobility. Medical record review of the Wound/Skin Healing Record dated March 7, 2012, revealed, .pre-admit .stage III (pressure ulcer) .Right heel .0.5 x 0.9 x (less than) 0.2 (centimeters) .wound bed brown (eschar) . Medical record review of the Wound/Skin Healing Record dated April 3, 2012, revealed, .(right heel) 0.4 x 0.7 x (less than) 0.2 (centimeters) .granulation tissue .slough .brown eschar . Review of the next Weekly Wound Report dated April 17, 2012 (two week time period from the last assessment) revealed .(right) lateral heel stage 3 0.4 x 0.7 (less than) 0.2 (centimeters) .loose eschar . Medical record review of a skin assessment dated [DATE], revealed, .small area of eschar to (right) heel .0.5 cm x 1 cm .no other skin breakdown noted . Medical record review of a skin assessment dated [DATE], revealed, .healing stage (2) (pressure ulcer) Rt (right) heel Stage (2) (pressure ulcer) coccyx-noted 7/4/12 Reddened area around coccyx .Pressure sores are to be measured weekly by skin assessment nurse . Medical record review revealed the wound assessment completed on July 6, 2012 for the right heel pressure ulcer did not describe the size or color of the wound. Medical record review revealed the next wound assessment dated [DATE], revealed, . eschar on (right heel) (1cm x 0.5 cm) 2 stage (2) wounds on coccyx ( .3 cm x 1.5 cm) ( .1.5 cm x 1 cm) Excoriated around wound bilat (bilateral) buttocks .Pressure sores are to be measured weekly by the skin assessment nurse . Medical record review of the care plan dated March 15, 2012, revealed .Perform complete skin assessment and record .1 time weekly starting 03/15/2012 . Interview on July 11, 2012, at 2:15 p.m., with the Director of Nursing, in the conference room, confirmed the pressure ulcer on the coccyx identified on July 4, 2012 was found as a stage II sore. This resident was assessed on admission as hi-risk for pressure sores and required extensive assistance with bed mobility. Interview on July 16, 2012, at 1:30 p.m., with the Director of Nursing, in the hall, confirmed no wound assessment with a full description of the size and color had been completed for the pressure ulcer on the right heel the week of April 10, 2012, or from June 12, 2012 until July 11, 2012. Medical record review of a Dietary Note dated April 19, 2012, revealed, .admitted [DATE] .stage (3) (right) lateral heel, labs alb ([MEDICATION NAME]) 2.5 (reference range 3.2-4.6) on 3/3/12 .Recommend Prosource liquid 1 oz (ounce) bid (twice a day) . Medical record review of a High Risk Follow-Up form dated May 17, 2012, signed by the Registered Dietician, revealed .unstageable decub (decubitus) (right) lateral heel .Recommend 1 oz liquid protein in 6-8 oz juice or other liquid bid (twice a day), [MEDICATION NAME] (appetite stimulant) 400mg (milligrams) bid . Medical record review of a physician's order dated May 18, 2012, revealed .1 oz liquid protein bid and [MEDICATION NAME] 400 mg bid . Medical record review of the Medication Administration Record [REDACTED]. Interview on July 11, 2012, at 2:15 p.m, with the DON, in the conference room, confirmed a delay (from April 19, 2012 until May 21, 2012, thirty-one day lapse) in starting the dietary recommendation of prosource. Review of the facility policy Stage III Pressure Ulcer, revealed, .Cleanse area with normal saline or wound cleanser .obtain physician order for [REDACTED].If indicated, Enzymatic debridement .to Necrotic area and apply [MEDICATION NAME] or saline moist loose gauze and cover dressing QD . Medical record review of the Treatment Records dated March 7, 2012, through March 31, 2012, and April 1, 2012, through July 31, 2012, revealed a treatment of [REDACTED]. Medical record review revealed no physician's order for the [MEDICATION NAME] treatment or any physician ordered treatment since the resident's admission on March 7, 2012 for the stage III pressure ulcer to the right heel. Interview on July 11, 2012, at 10:40 a.m. with the DON, in the conference room, confirmed no physician's order had been obtained since the resident's admission on March 7, 2012, for treatment for [REDACTED]. Observation and interview on July 11, 2012, at 5:30 p.m. with the resident's physician revealed two stage 2 pressure ulcers on the coccyx and a pressure ulcer on the right heel with eschar, as described by the physician. Interview with the physician, at this time confirmed the physician was unable to recall being notified of the stage III pressure ulcer to the resident's right heel. Medical record review of the care plan reviewed on May 31, 2012, revealed .Use pillows, pads, or wedges to reduce pressure on heels and pressure points . Observation and interview on July 12, 2012, at 8:30 a.m. with Certified Nursing Assistant (CNA) #1 revealed the resident lying on the bed with the heels touching the mattress. Review of the Dietitian Contract revealed, .All patients with pressure ulcers (stage 2 or more) will be assessed monthly by the registered dietician . Interview on July 16, 2012, at 10:45 a.m. in the conference room, with the Clinical Nutrition Director, confirmed the resident was not assessed by the Registered Dietician until April 19, 2012, a delay in assessment of forty-three days from the resident's admittance on March 7, 2012, with a stage 3 pressure ulcer. Resident #107 was admitted to the faciility on May 25, 2012, with [DIAGNOSES REDACTED]. Medical record review revealed the resident was discharged to the hospital on June 29, 2012. Medical record review of the admission Minimum Data Set, dated dated dated [DATE], revealed the resident scored fourteen on the Brief Interview for Mental Status (BIMS) indicating the resident was independent with daily decision making, required extensive assistance with bed mobility, transfers and walking, had a Stage I pressure ulcer, was at risk for development of pressure ulcers, and a pressure reducing device was used on the bed and chair. Medical record review of the (named skin) Risk Assessment Scale dated May 25, 2012, revealed a score of seventeen (17) and .A score of 17 or below requires a weekly skin assessment/documentation in the medical record . Medical record review of the Interim Care Plan dated May 25, 2012, revealed .Resident is at risk for skin breakdown due to [MEDICATION NAME] therapy, auto immume disease .Stg (stage) 1 coccyx .turn q (every) 2 hrs (hours) and PRN (as needed) . Medical record review of the admission nursing assessment dated [DATE], revealed the resident had an excoriated sacrum. Medical record review of the skin assessment dated [DATE], revealed the sacral area was red and a protective ointment was being applied daily. Medical record review revealed the next skin assessment was completed on June 8, 2012, and revealed .coccyx area reddened with a pencil eraser sized area opened . Interview on July 11, 2012, at 3:25 p.m., with the Assistant Director of Nursing (ADON), in the conference room revealed the resident was placed on a pressure reducing mattress upon admission to the facility. Continued interview revealed the resident was to receive a weekly skin assessment and confirmed the resident did not receive a skin assessment from May 29, 2012, until June 8, 2012, a three day delay. Interview on July 12, 2012, at 12:25 p.m., with the physician, in the Administrator's office, revealed the physician had visited the resident on June 8, 2012, when the pressure ulcer increased to Stage II at the request of the nursing staff, the resident frequently rejected care, (turning and repositioning, and medications to assist with wound healing). Continued interview revealed the resident's pressure ulcer declined quickly and was unavoidable due to the resident's non-compliance.	2016-02-01

CMS-Nursing-Home-Full-Deficiencies

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