Cordova Wellness And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for 3 of 33 (Resident #3, #147 and #181) residents reviewed for MDS discrepancies. The findings include: 1. Review of the facility's policy titled, RAI (Resident Assessment Instrument) -MDS 3.0 Completion, dated 1/1/2023, revealed .Residents are assessed using a comprehensive assessment process, in order to identify care needs . 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Encephalopathy, Osteoarthritis, Schizoaffective Disorder, and Hypothyroidism. Review of the quarterly MDS assessment dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS section O0110 was inaccurately coded to reflect Resident #3 received dialysis. Review of the Physician Orders dated 3/11/2026, revealed Resident #3 did not have an order…

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 maintain emergency supplies at the bedside for 1 of 1 (Resident #11) sampled residents reviewed for tracheostomy (a surgically created opening in the neck to help with breathing) care. The findings include: 1. Review of the undated facility policy titled, Tracheostomy Care, Disposable Cannula [a small tube that is inserted into an open area of the body] revealed .The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences.Maintain a suction machine, a supply of suction catheters, correctly sized cannulas, and an ambu bag [a hand held device used to deliver air or oxygen to the lungs through a self-inflating bag in order support or replace breathing during an emergency] easily accessible for…

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, observation, and interview, the facility failed to ensure that an account of all controlled medications was accurately reconciled for 1 of 10 medication carts (700 Hall Medication Cart #4). The findings include: 1. Review of the undated facility policy titled, Medication Administration, revealed .If medication is a controlled substance, sign the narcotic book .Correct any discrepancies and report to nurse manager . 2. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE], with diagnoses including Traumatic Brain Injury, Paralytic Syndrome, Diabetes, and Anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #43 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was moderately cognitively impaired. Review of the Physician's Orders dated 5/15/2025, revealed .Gabapentin [used for pain]100 MG [milligram] .Give 1 capsule by mouth three times a day .…

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, observation, and interview, the facility failed to maintain and ensure the prevention and spread of infection when 4 of 8 (the Infection Preventionist Licensed Practical Nurse (LPN) A and B, and Registered Nurse (RN) C) staff failed to use Personal Protective Equipment (PPE) during wound care, failed to use proper hand hygiene, and failed to clean reusable equipment between residents. The findings include: 1. Review of the undated facility policy titled, Medication Administration, revealed .Medications are administered by licensed nurses, or other staff who are legally authorized to do so .in a manner to prevent contamination of infection .Wash hands prior to administering medication per facility protocol and product . Review of the undated facility policy titled, Hand Hygiene, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all…

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.

Based on personnel file review, facility document review and interview, Administration failed to ensure that nursing services were provided by qualified personnel when the facility hired an imposter nurse (Imposter Nurse A) to function as a Licensed Practical Nurse (LPN) using another LPN's (LPN C) Tennessee license on 2 separate occasions. Imposter Nurse A worked at the facility from 02/13/2023 to 06/06/2023 and was hired a second (2nd) time at the facility from 05/03/2024 to 06/24/2024. The findings include: 1st Hire: Review of Imposter Nurse A's personnel file revealed an employee application dated 02/08/2023 with a Social Security Number (SSN) that did not match the W-4 form dated 02/13/2023. Review of the I-9 form (Employment Eligibility Verification) used to verify the identity and legal authorization of individuals hired for employment in the United States dated 02/13/2023, revealed Imposter Nurse A's legal first and last name, along with a birth certificate and a valid Driver's license from another state. The last name used on the I-9 form was the same as the Driver's…

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.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by opened, unlabeled, undated food in the walk-in cooler and in the dry storage area, a mop lying in a bucket of dirty water near the stove during meal preparation, a dirty kitchen floor, a dirty deep fryer, a dirty convection toaster, a dirty food slicer, a scoop lying in the sugar bin, a Styrofoam cup lying in the raisin bran bin, carbon build-up on 2 sauté pans, opened, undated, unlabeled food items in the cooler, a dirty plate warmer, dirty 3-tiered cart, and a dirty tray line conveyor in the serving line area. The facility had a census of 133 with 105 of those residents receiving a tray from the kitchen. The findings include: Review of the facility's undated policy titled, .Sanitation Inspection, revealed .It is the policy of this facility .to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations .All food services areas shall be kept clean, sanitary, free from…

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, observation, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance were provided related to nail care, skin care, and facial hair for 4 of 6 sampled residents (Resident #27, #41, #58, and #115) reviewed for ADLs. The findings include: Review of the facility's policy titled, .Fingernails/Toenails, Care of, dated 10/2017, revealed .The proper care of fingernails .The purpose of this procedure is to clean the nail bed, to keep the nails trimmed, and to prevent infections. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . Review of the facility's undated policy titled, .Activity of Daily Living ., revealed .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good .personal .hygiene . Review of the medical record, revealed Resident #27 was admitted to the facility on [DATE] with diagnoses of Heart Disease, Diabetes,…

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, observation, and interview, the facility failed to ensure enteral feedings with automatic flushes were infusing at the correct rate and failed to ensure enteral feedings and automatic flush bags were correctly labeled for 3 of 3 sampled residents (Resident #17, #65, and #94) reviewed for enteral feedings. The findings include: Review of the facility's undated policy titled, Care and Treatment of Feeding Tubes, revealed .Feeding tubes will be utilized according to physician orders .Open system feeding bags will be changed every 24 hours . Review of the medical record, revealed Resident #17 was admitted to facility on 2/24/2022 with diagnoses of Hemiplegia, Hemiparesis, Gastrostomy (a tube inserted into the stomach to administer liquid nourishment), and Cerebral Infarction. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #17 was assessed with a Brief Interview for Mental Status score (BIMS) of 1, which indicated Resident #17 was…

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, observation, and interview, the facility failed to provide the necessary respiratory care and services when a tracheostomy tubing condensation collection bag was lying on the floor, humidification bottles were on the floor, a dusty fan was blowing on a resident's tracheostomy, and there were no physician orders for oxygen for 4 of 4 sampled residents (Resident #23, #41, #44 and #45) reviewed for oxygen therapy. The findings include: Review of the facility's policy titled, .Trach [Tracheostomy] Care, dated 10/2017, revealed .Our policy is to provide care for the resident with a tracheostomy present to prevent nosocomial infections . Review of the facility's policy titled, .Oxygen, dated 12/2017, revealed .Oxygen therapy is administered to the resident only upon the written order of a licensed physician . Review of the medical record, revealed Resident #23 was admitted to the facility on [DATE] with diagnoses of Respiratory Failure and Tracheostomy. Review of the…

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 provide information regarding a resident's right to formulate an Advanced Directive for 1 of 32 sampled residents (Resident #113) reviewed for Advanced Directives. The findings include: Review of the facility's policy titled, admission Process: Advance Directives, dated 10/2017, revealed .protect the resident's rights and resident choice to advance life support initiatives upon admission/readmission .advance directives .will be signed prior to admission . Review of the medical record, revealed Resident #113 was admitted to the facility on [DATE] with diagnoses of Acute Respiratory Failure, Gastrostomy, Guillain-Barre Syndrome, and Convulsions. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #113 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Review of Resident #113's medical record, revealed there was no documentation the resident or their…

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, observation, and interview, the facility failed to ensure the environment was free from accident hazards for 1 of 4 sampled residents (Resident #19) reviewed for accidents. The findings include: Review of the facility's undated policy titled, Accidents and Supervision, revealed .The resident environment remains as free of accident hazards as is possible .The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents . Review of the medical record, revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Diabetes, Heart Disease, Dementia, and Obesity. Review of the quarterly Minimum Data Set, dated [DATE], revealed Resident #19 had moderately impaired cognition. Review of the Care Plan revised on 4/20/2022, revealed, .The resident's safety will be maintained . Observation in the Dining Room on 6/20/2022 at 9:18 AM and…

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 follow the pharmacy recommendations in a timely manner 1 of 5 sampled residents (Resident #12) reviewed for unnecessary medications. The findings include: Review of the facility's policy titled POLICIES AND PROCEDURE Pharmacy Services, dated 6/1/2021, revealed The consultant pharmacist documents activities performed and services provided on behalf of the residents and the facility. A written or electronic report of findings and recommendations resulting from the activities as described above is given to the, attending physician, director of nursing, medical director and others as may be appropriate (e.g. [example] administrator, regional manager .) monthly. The facility has a process to ensure that the findings are acted upon . Review of medical record, revealed Resident #12 was admitted on [DATE], and readmitted on [DATE], with diagnoses of Femur Fracture, Diabetes, Acute Failure Kidney, Dementia and Urinary Retention. 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.