Life Care Center Of East Ridge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation, and interview, the facility failed to ensure temperatures for the kitchen beverage cooler and high temperature dishwasher were maintained at the recommended temperature to minimize growth of microorganisms. The findings include:Review of the facility policy titled, Food Safety and Sanitation, revised 9/8/2022, revealed .Ambient temperatures in refrigerators/coolers are to remain at or below 41* F [degrees Fahrenheit] .Temperatures are recorded at least twice daily on the Refrigerator/Freezer Temperature Log .any problems will be reported immediately to the Director of Food and Nutrition Services /Maintenance .Dish machine will be used in accordance with the manufacturer specification .The temperature of the wash rinse cycle will be recorded a minimum of three times per day on a High Temperature Dish Machine Log .A surface temperature test using a surface temperature indicator strip should be completed and logged daily on the High Temperature Dish Machine Log .Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 properly store a nebulizer mask (a drug delivery device used to administer medication in the form of a mist which is inhaled into the lungs) for 2 residents (Resident #94 and Resident #115) of 5 sampled residents.The findings include: Review of the facility's undated policy titled, Lippincott procedures-Nebulizer Treatment, small volume, revealed .The equipment the needs to be cleaned with an EPA [Environmental Protection Agency] registered hospital disinfectant. Allowed to air dry, and then bagged .Nebulizer circuit should be stored in a patient-care set-up bag. Labeled with the patient's name and dated . Review of the medical record revealed Resident #94 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) with (Acute) Exacerbation, Chronic Respiratory Failure with Hypoxia, Emphysema, and Solitary Pulmonary Nodule. Review of the admission Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to ensure assessment for contraindications to COVID-19 vaccines were documented in the medical record for 1 resident (Resident #1) of 5 residents reviewed for immunizations.The findings include:Review of the facility's policy titled, COVID-19 (SARS-CoV-2) Vaccination Program Policy for Residents, revised on 4/22/2025, revealed .facility will ensure that residents are offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident has already been immunized .Procedure Vaccination Screening .The facility should check for the following .Prior vaccination status .The presence of medical precautions and contraindications .Once screening is completed the facility should offer residents vaccination against COVID-19 .Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Polyneuropathy, Emphysema, Severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, and interviews the facility failed to ensure enhanced barrier precautions were followed for 1 resident (Resident #104) of 16 residents reviewed for enhanced barrier precautions (EBP). The findings include:Review of the facility's policy titled, Enhanced Barrier Precautions, dated 6/3/2024 revealed .The facility should use Enhanced Barrier Precautions (EBP) .during high-contact resident care activities .Wounds and/or indwelling medical devices .Indwelling medical devices examples include central lines, urinary catheters .Review of the medical record revealed Resident #104 was admitted to the facility on [DATE] with diagnoses of Neuromuscular Dysfunction of Bladder and Retention of Urine.Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #104 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review the resident had an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview the facility failed to assess 2 residents (Residents #1 and #10) for medical contraindications prior to providing the Influenza vaccine of 5 residents reviewed for immunizations. The findings include:Review of the facility's policy titled, Influenza Vaccine Policy for Residents, dated 9/24/2024, revealed .Medical contraindication refers to a condition or risk that precludes the administration of a treatment or intervention because of the substantial probability that harm to the individual may occur .Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated, or the resident has already been immunized during this time period .Procedure - Influenza Vaccine .The resident is assessed for possible contraindications .If contraindications are noted or if the nurse has any questions based on the assessment, the physician is notified of the assessment findings for further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, review of the Resident Assessment Instrument (RAI) Manual 3.0, medical record review, observations, and interviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 residents (Resident #25 and #11) of 18 residents reviewed for MDS assessments. The findings include: Review of the facility's policy titled, Resident assessment Instrument & Care Plan Development, dated 8/22/2022, revealed .The facility will follow the procedures set forth in the Resident Assessment Instrument User's Manual 3.0 when completing the MDS . Review of the RAI Manual dated 10/2023, revealed .The RAI process has multiple regulatory requirements .the assessment accurately reflects the resident's status .a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals .one of the most important functions .accurate picture of the resident's current health status . Medical record review revealed Resident #25 was admitted to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASARR) after new mental health diagnoses were identified for 1 resident (Resident #44) of 12 residents reviewed for PASARR. The findings include: Review of the facility's policy titled, Pre-admission Screening and Resident Review, dated 10/4/2022, revealed, .The facility will ensure that potential admissions are .screened for possible serious mental disorders or intellectual disabilities .A negative Level I screen .ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later .Any resident with newly evident or possible serious mental disorder .or a related condition must be referred, by the facility to the appropriate state-designated mental health or intellectual disability authority for review . Medical record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including Anxiety,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) was accurate upon admission for 1 resident (Resident #11) of 12 residents reviewed for PASARR. The findings include: Review of the facility's policy titled, Pre-admission Screening and Resident Review, dated 10/6/2022, revealed .facility will ensure that potential admissions are .screened for possible serious mental disorders or intellectual disabilities and related conditions .Referring all .residents .with .possible serious mental disorder .or a related condition for level II resident review . Review of a PASARR Level I Screen for Resident #11 dated 2/8/2024, revealed .No mental health diagnosis is known or suspected . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Anxiety, and Delusional Disorder. During an interview on 6/5/2024 at 1:45 PM, the Registered Nurse (RN)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to implement a comprehensive care plan to reflect a Post Traumatic Stress Disorder (PTSD) diagnosis for 1 (Resident #24) of 18 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Person Centered Care Plan, dated 8/16/2022, revealed .Each person will have a person-centered comprehensive care plan developed and implemented to meet .the resident's medical, physical, mental and psychosocial needs .care plan will include measurable goals, timeframes to meet the patient's .psychosocial needs . Review of the facility's policy titled, Trauma Informed Care, dated 8/22/2023, revealed .Based on the comprehensive assessment of a resident .who has a history of .post-traumatic stress disorder receives appropriate treatment and services . Medical record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety, and PTSD. Review of a comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, and interview the facility failed to secure medications for 1 resident (Resident #7) of 18 residents screened for accidents and hazards. The findings include: Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biologicals, dated 8/7/2023, revealed .Store all drugs and biologicals in locked compartments .Facility should ensure that all medications .are securely stored in a locked cabinet/cart or locked medication room that is inaccessible . residents . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Depression, and Anxiety. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of the Nursing Monthly Summary for Resident #7 dated 5/30/2024, revealed the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, interview, and observation, the facility failed to follow a physician's order for fluid restrictions for 2 residents (#16 and #38) of 3 residents reviewed for fluid restrictions and failed to obtain weights as ordered for 1 resident (#16) of 3 residents reviewed for weights. The findings include: Review of the facility's policy titled, Monitoring Intake and Output, reviewed 7/8/2021, showed .Intake .monitoring may be initiated in the following circumstances .Resident who is on a fluid restriction .Intake .will be documented in the electronic health record . Review of the facility's policy titled, Weights and Heights, revised 7/17/2021, showed .residents are weighed within 24 hours of admission .and as needed thereafter .as determined by the .physician order . Resident #16 was admitted to the facility on [DATE] with diagnoses including Acute Systolic Congestive Heart Failure (CHF), Hyponatremia (low sodium), Pleural Effusion (an abnormal collection of fluid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 develop a care plan for 2 residents (#10 and #27) of 18 residents reviewed for care plans. The findings include: Review of the facility policy titled Comprehensive Care Plans and Revisions dated 3/2/2022, showed .The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan . Resident #10 was admitted to the facility on [DATE] with diagnoses including Acute Kidney Failure, Dementia, Type 2 Diabetes Mellitus, Hypertension, and Retention of Urine. Review of a physician's order dated 6/6/2022, showed .Indwelling catheter to straight drainage . Review of a comprehensive care plan initiated on 6/6/2022, showed Resident #10 had not been care planned for the use of a urinary catheter. Review of a 5-day Minimum Data Set (MDS) assessment dated [DATE], showed Resident #10 had a urinary catheter in place. Observations on 7/18/2022 at 11:20 AM, 7/19/2022 at 2:00 PM, and 7/20/2022…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, and interviews, the facility failed to follow a physician's order in obtaining a follow up urology (branch of medicine concerned with the function of the urinary system) appointment to assess an indwelling urinary catheter (a tube inserted into the bladder that remains in place to provide continuous urinary drainage) for 1 resident (#10) of 4 residents reviewed for urinary catheters. The findings include: Review of a facility policy titled Indwelling Urinary Catheter .Management dated 4/1/2022, showed .ensure that resident admitted with a urinary catheter .have the following areas addressed .Timely and appropriate assessments related to the indication for use of an indwelling catheter . Resident #10 was admitted to the facility on [DATE] with diagnoses including Acute Kidney Failure, Dementia, Type 2 Diabetes Mellitus, Hypertension, and Retention of Urine. Review of a hospital Discharge summary dated [DATE], showed .Discharge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to maintain a completed Physician Order for Scope of Treatment (POST) form in the medical record for 1 resident (#10), and failed to obtain a physician's order for an accurate code status for 1 resident (#30) of 18 residents reviewed for Advance Directives. The findings include: Review of the facility policy titled Advance Directives and Advance Care Planning revised [DATE] showed .Residents have the right to self-determination regarding their medical care. This includes the right of an individual to direct his or her own medical treatment, including the right to execute or refuse to execute an advance directive .It is also required that the patient is asked about advanced directives, and to document any wishes the patient might have with regard to the care they want or do not want .Physician Orders for Life-Sustaining Treatment [or POST] .form that records patients' treatment wishes so that emergency personnel know what…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.