2024 Year in Review - Tennessee

The facility failed to maintain sanitary conditions for residents' personal laundry, which was improperly handled and stored, leading to insufficient cleaning. Additionally, the facility did not adhere to CDC guidelines for excluding COVID-19 positive employees from work during an outbreak, increasing the risk of virus spread. The facility also failed to post Enhanced Barrier Precautions signage on three resident rooms, placing residents at risk of serious harm.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility's QAPI program failed to identify and address deficiencies in infection control practices, leading to improper handling of residents' laundry and premature return of COVID-19 positive staff. This oversight resulted in a COVID-19 outbreak affecting 22 residents and 13 employees, with seven staff returning to work before completing isolation. The facility also had repeated abuse-related deficiencies, which were not effectively addressed by the QAPI committee.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility failed to handle residents' laundry safely, exposing them to pathogens, and allowed COVID-19 positive staff to work with non-COVID-19 residents, increasing infection risk. Additionally, inadequate staffing led to missed outpatient appointments and showers for residents.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The QAPI committee at the facility failed to effectively identify and address quality deficiencies, resulting in resident neglect, inadequate investigations of adverse events, and ineffective pain management. Despite implementing a Performance Improvement Plan for wound care, the facility did not maintain proper oversight, leading to an increase in wound infections and Immediate Jeopardy citations. The Administrator's involvement was limited, and the previous wound care nurse was unresponsive to feedback.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility administration failed to provide adequate oversight and supervision, resulting in deficiencies such as incomplete investigations into major injuries of unknown origin for two residents, inadequate wound care management for multiple residents, and ineffective pain management for a resident with a major injury. Additionally, the administration did not conduct effective QAPI meetings to address quality deficiencies, leading to citations for Immediate Jeopardy and substandard quality of care.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility failed to investigate and address allegations of sexual abuse by a resident, affecting three other residents. Despite reports of nonconsensual advances and inappropriate behavior, the facility did not conduct investigations or implement care plan interventions. Staff and residents reported ongoing issues, but the facility's inaction led to Immediate Jeopardy, posing a risk of serious harm.

Fine: $95,23212 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility failed to use the least restrictive interventions or restraint devices for four residents, resulting in extended use of restraints. Despite the facility's policy to use the least restrictive safety device, residents with severe cognitive impairments were placed in restraints for extended periods without successful reduction attempts. Interviews confirmed the facility's continued use of restraints for resident safety, failing to adhere to the policy.

Fine: $15,420

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility implemented a Restraint Free Environment policy, discontinued restraints for affected residents, and updated care plans. All clinical staff, providers, and therapy managers received education on the new policy, which will be included in new hire orientation and quarterly training. Restraints were removed and stored securely, and responsible parties were notified. The facility engaged ongoing clinical consulting services to support compliance.

The facility failed to use the least restrictive interventions or restraint devices for four residents, resulting in extended use of restraints. Despite policies requiring weekly reviews to decrease restraints, residents with severe cognitive impairments were placed in restrictive devices without attempts to reduce or eliminate them. Interviews confirmed the facility's failure to adhere to its restraint policy.

Fine: $15,420

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility implemented a Restraint Free Environment policy, educated all clinical and administrative staff, and notified residents' families. Restraints were removed, and assessments for safe restraint reduction were completed, resulting in updated care plans and appropriate seating arrangements. The Clinical Consultant provided education on restraint requirements and is available 24/7. Ongoing clinical consulting services are in place.

The facility failed to provide necessary wound care for several residents, resulting in unstageable wounds and infections. Despite having policies and a QAPI plan, the facility did not effectively implement wound care treatments, leading to Immediate Jeopardy. Residents suffered from untreated wounds, some requiring hospital transfers, highlighting significant neglect in care management.

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility failed to maintain safe hot water temperatures and provide adequate supervision, resulting in dangerously elevated water temperatures and injuries to residents. Maintenance staff lacked proper training, and there was a significant communication breakdown among the staff. Additionally, improper use of a mechanical lift led to a resident's lumbar compression fracture, and another resident fell due to inadequate supervision.

Fine: $425,010129 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility did not thoroughly investigate multiple abuse allegations involving a cognitively impaired resident with a history of inappropriate behaviors. Incidents included unwanted touching, inappropriate sexual behaviors, and verbal abuse, causing distress to several residents. Despite documentation of these behaviors, the facility's staff, including nurses and administrators, failed to report and investigate the incidents promptly. LPN J witnessed inappropriate behaviors but did not report them initially, and the Administrator and DON showed a lack of understanding regarding abuse reporting and investigation requirements.

Fine: $105,446

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility's QAPI program failed to identify and address quality deficiencies related to injuries of unknown origin and abuse for several residents. The program did not conduct thorough investigations or develop person-centered interventions, resulting in an Immediate Jeopardy situation. Incidents involving injuries and resident-to-resident altercations were not reported or investigated properly, and the facility's policies on injury and abuse prevention were not effectively implemented.

Fine: $138,801110 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility implemented corrective actions including educating the Administrator and DON on identifying, investigating, and reporting abuse and injuries of unknown origin, with staff receiving similar training led by the Risk Manager and DON. The Director of Reimbursement and Clinical Services will oversee daily operations, while the Governing Body and corporate staff will assess the need for additional oversight. Ad-Hoc QAPI meetings will review audit results and trends, and SEC calls will continue to discuss incidents, with educational plans developed based on identified patterns.

The facility's Governing Body failed to provide effective oversight, leading to unreported and uninvestigated resident-to-resident altercations and injuries of unknown origin. A resident with severe cognitive impairment sustained a fracture that was not properly addressed, and another resident with dementia was injured in an altercation. The facility's QAPI program was ineffective, and the Administrator admitted to not reviewing incident reports adequately.

Fine: $138,801110 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility implemented corrective actions including educating the Administrator, DON, and staff on identifying and reporting abuse, with the DON monitoring compliance. The Director of Reimbursement and Clinical Services will oversee daily operations, while the Governing Body and corporate staff will assess the need for additional oversight. Ad-Hoc QAPI meetings and SEC calls will review audits and incidents, and educational plans will be developed based on identified trends.

The facility's administration failed to provide effective oversight, leading to deficiencies in abuse prevention and reporting. Incidents involving resident-to-resident altercations and injuries of unknown origin were not properly investigated or reported, placing residents in immediate jeopardy. The administration did not follow the facility's abuse policy, often dismissing incidents due to residents' cognitive impairments, and failed to maintain an effective QAPI program.

Fine: $138,801110 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility implemented corrective actions including education for the Administrator, DON, and staff on identifying and reporting abuse, with compliance monitored by the DON. Oversight is provided by the Director of Reimbursement and Clinical Services, with additional oversight determined by the Governing Body and corporate staff. Regular QAPI and SEC meetings are held to review audits, incidents, and trends, with educational plans developed based on findings.

The facility failed to develop and implement comprehensive person-centered care plans for residents, leading to multiple resident-to-resident altercations and injuries. Residents with aggressive behaviors and cognitive impairments were not provided with appropriate interventions, and care plans were not updated after incidents. The lack of accountability in care planning contributed to immediate jeopardy for the residents involved.

Fine: $138,801110 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility failed to investigate an injury of unknown origin and multiple resident-to-resident altercations, which were potential indicators of abuse. A resident with severe cognitive impairment sustained a left femur fracture without a thorough investigation or incident report. Additionally, altercations between residents resulted in injuries, but the facility's investigations were incomplete, lacking necessary documentation and adherence to policies. The failure to investigate these incidents placed residents at risk and resulted in a citation for Immediate Jeopardy.

Fine: $138,801110 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility implemented an acceptable Removal Plan for F-610, which was validated on site by the surveyor.

The facility failed to report and investigate incidents of abuse and injuries of unknown origin for several residents, leading to a deficiency in compliance with regulatory requirements. A resident sustained a left femur fracture with an undetermined cause, and no thorough investigation was conducted. Additionally, the facility failed to report and investigate resident-to-resident altercations involving cognitively impaired residents, resulting in injuries. The facility's policies on abuse and unusual occurrences were not followed, and the incidents were not reported to state agencies, local law enforcement, or APS. This placed the residents in Immediate Jeopardy, leading to a citation for substandard quality of care.

Fine: $138,801110 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility failed to protect residents from abuse and did not identify resident-to-resident altercations as abuse, affecting several residents with cognitive impairments. A resident with severe cognitive impairment wandered into other residents' rooms without interventions, resulting in injuries from an altercation with another aggressive resident. Despite the altercation, no new interventions were implemented, and staff were observed not redirecting the wandering resident. Another resident with a history of aggression was involved in multiple incidents, yet her care plan did not address her behavior. The facility's policies on abuse prevention and intervention were not effectively implemented, leading to a situation of Immediate Jeopardy.

Fine: $138,801110 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

A facility failed to prevent abuse and neglect, resulting in multiple incidents involving residents with cognitive impairments and psychiatric disorders. An alert male resident with a history of aggressive behavior physically assaulted a female resident who wandered into his room, and verbally abused another in the dining room. The facility did not adequately monitor or redirect residents, nor did it report or address a separate altercation between two other residents, highlighting systemic issues in ensuring a safe environment.

Fine: $351,55540 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Corrective actions included placing stop signs on a resident's room to manage wandering, ensuring staff accompany a resident during meals, training staff on abuse policies, monitoring residents for behaviors that may increase abuse risk, and involving the QAPI committee to oversee compliance and address questions. Additionally, both residents will continue receiving psychiatric services.

The facility failed to ensure proper infection control practices when using a multi-use glucometer, as multiple nurses did not follow the required disinfection procedures, placing residents at risk for bloodborne pathogen contamination. This deficiency was identified as Immediate Jeopardy.

Fine: $211,2448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility failed to protect residents from abuse and neglect, resulting in Immediate Jeopardy. A resident exhibited inappropriate sexual behaviors towards another resident, and the facility did not implement adequate interventions. Another resident was neglected after a fall, leading to their death. Additionally, a resident was physically abused by another resident, resulting in pain and injury. The facility's policies and procedures for abuse prevention and response were not effectively implemented.

Fine: $211,2448 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

The facility failed to maintain accurate records and promptly identify the loss or potential diversion of controlled medications, resulting in Immediate Jeopardy for seven residents. Fentanyl patches were tampered with, and 509 Oxycodone and Hydrocodone tablets were missing and unaccounted for. The required procedures for signing Pharmacy manifest sheets and controlled medication accountability records were not consistently followed.

Fine: $147,898

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

A reconciliation of controlled medications was conducted by the DON and SCC, with discrepancies found only on Hall #3. Legal and regulatory entities were notified of any misappropriation. Delivery manifests were reviewed, and residents were assessed for pain. A secured cabinet with dual locks was installed for overflow medications, and a new process for medication removal was implemented. Staff received education on the Abuse and Misappropriation Policy.