Dickson Health And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interviews the facility failed to honor food preferences for 1 of 24 (Resident #35) residents. The findings include: 1. Review of the facility policy titled, Resident Food Preferences . dated 10/2024, revealed .Nutritional assessments will include an evaluation of individual food preferences. Residents receive food prepared in a form designed to meet individual needs, including preferences . 2. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Morbid (Severe) Obesity, Muscle Weakness, Bariatric Surgery Status, and Gastro-Esophageal Reflux Disease. Review of Progress Note dated 10/15/2024, revealed . Continue to honor food preferences and encourage fluid restriction compliance Review of the care plan dated 12/13/2024, revealed .at risk for impaired nutrition .Honor food preferences and update PRN [as needed] . Review of the annual Minimum Data Set…

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 review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to complete a comprehensive resident admission assessment within 14 calendar days after admission for 1 of 21 residents (Resident #215) sampled residents reviewed. The findings include: 1.Review of the RAI Manual Version 3.0 dated 10/2023, revealed, .For the admission assessment, the MDS [Minimum Data Set] Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600) . For the admission assessment, the Care Area Assessment (CAA) Completion Date (V0200B2) must be no later more than 13 days after the Entry Date (A1600) . 2. Review of the medical record revealed Resident #215 was admitted to the facility on [DATE], with diagnoses which included Wedge Compression Fracture of T7 - T8 (break in the vertebrae located at the 7th and 8th thoracic level of the spine), Wedge Compression Fracture of T11-T12 (break in the vertebrae located at the 11th and 12th…

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 review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review and interview, the facility failed to complete a significant change assessment for 1 resident (Resident #57) of 21 residents reviewed. The findings include: 1.Review of CMS's RAI Version 3.0 Manual Chapter 2 dated 10/2023 revealed .Guidelines to Assist in Deciding If a Change Is Significant or Not .When a .Resident enrolls in a hospice program .must be within 14 days from the effective date of the hospice election . 2. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included Alzheimer's Disease, Dementia, Hyperlipidemia, and Hypothyroidism. Review of Resident #57's Discharge Summary from Hospital #1 dated 12/2/2024, revealed, General Information .12/2 [12/2/2024] return to LTC [Long Term Care, hospice/palliative care to follow . Review of the Quarterly Minimum Data Set (MDS)…

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 review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete resident assessments, using the Centers for Medicare & Medicaid Services-specific RAI (Resident Assessment Instrument) process, within the regulatory time frames for 2 of 21 sampled residents (Resident #28 and #48) reviewed for completion of the MDS resident assessments. The findings include: 1. Review of the MDS 3.0 RAI Manual v (version) 1.19.1 October 2024, page 5-2 revealed . For the admission assessment, the Care Area Assessment (CAA) Completion Date .must be no later more than 13 days after the Entry Date .For the Annual assessment, the CAA Completion Date .must be no later than 14 days after the ARD 2. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dementia, Contractures of Bilateral Lower Legs, Depression and Anxiety. Review of the annual MDS with an Assessment…

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 comprehensive care plans for 2 of 21 (Residents #55 and #215) sampled residents. The findings include: 1. Review of the facility policy titled, Comprehensive Care Plans, dated 8/2024, revealed .An individualized comprehensive centered care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental, cultural and psychological needs is developed for each resident .Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change .if a history of trauma, interventions for care that address such based upon known interventions from qualified professions, and interventions that the staff may use to eliminate or mitigate triggers that may cause re-traumatization .Each resident's comprehensive care plan is designed to .Incorporate identified problem areas .incorporate risk factors associated…

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 update or revise the care plans for 4 of 21 (Resident #55, #56, #57, and #220) sampled residents reviewed. The findings include: 1. Review of the facility policy titled, Comprehensive Care Plans, dated 8/2024, revealed .An individualized comprehensive centered care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental, cultural and psychological needs is developed for each resident .Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change . If a history of trauma, interventions for care that address such based upon known interventions from qualified professions, and interventions that the staff may use to eliminate or mitigate triggers that may cause re-traumatization .Each resident's comprehensive care plan is designed to .Incorporate identified problem areas .incorporate risk factors associated with…

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 1 of 21 sampled residents (Resident #215) had clean and groomed fingernails. The findings include: 1. Review of the facility policy titled, Care of Fingernails/Toenails, dated 10/2024 revealed, .The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming . 2. Review of the medical record revealed Resident #215 was admitted to the facility on [DATE], with diagnoses which included Wedge Compression Fracture of T7 - T8 (break in the vertebrae located at the 7th and 8th thoracic level of the spine), Wedge Compression Fracture of T11-T12 (break in the vertebrae located at the 11th and 12th thoracic level of the spine), Acute Respiratory Failure, Unspecified Cirrhosis of Liver, and Chronic Systolic Congestive Heart Failure. Review of Resident #215's admission Minimum Data Set (MDS) assessment dated…

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 follow Physician orders related to parameters for the use of as needed (PRN) pain medication for 1 of 5 sampled residents (Resident #44) reviewed for unnecessary medications; and related to Percutaneous Endoscopic Gastrostomy (PEG) medication administration for 1 of 6 sampled residents (Resident #3) reviewed for medication administration, and failed to collaborate care with Hospice Services for 1 of 3 sampled residents (Resident #515) reviewed for Hospice. The findings: 1. Review of the facility policy titled, General Dose Preparation and Medication Administration ., dated 2/2024, revealed .Prior to preparing or administering medications .Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record . Review of the facility policy titled, Hospice Program ., dated 10/2024, revealed .Obtain a physician's order for Hospice…

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 the facility policy, facility list of residents that wander, medical record review, observation and interview the facility failed to provide an environment free of accident hazards for 1 of 21 (Resident #34) sampled residents when nursing staff left razors open and unattended on a table in Resident #34's room. The findings include: 1. Review of the facility policy titled, Needlesticks and Cuts, dated 4/2024 revealed, .Personnel will follow our facility's established procedures to help prevent injuries caused by .sharp blades, broken glass, or other sharp instruments or devices .Staff shall place .sharp objects in puncture-resistant containers . 2. Review of the facility list of residents that wander revealed 5 residents that frequently wander within the facility. 3. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE], with diagnoses which included Unspecified Systolic Congestive Heart Failure, Muscle Weakness, Unsteadiness on feet, Need for Assistance with personal…

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 have a physician's order for a resident's dialysis treatments, failed to assess and monitor the dialysis site for a thrill (palpable vibration felt over a vessel), and infection, failed to weigh or get vital signs, and failed to have an accurate individualized care plan for 1 of 1 (Resident #48) sampled residents for dialysis. The findings include: 1. Review of the facility policy titled, Comprehensive Care Plans ., dated 8/2024, revealed .An individualized comprehensive centered care plan that includes measurable objectives and time frames to meet the resident's .needs is developed for each resident .Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change .Each resident's comprehensive care plan is designed to .Incorporate identified problem areas .incorporate risk factors associated with identified problems .The Care Planning/Interdisciplinary is…

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 obtain a Physician's Order for hospice care and a foley catheter for 1 of 21 (Resident #53) sampled residents. The findings include: 1. Review of the facility policy titled, Hospice Program ., dated 6/2021, revealed, .Obtain a physician's order for Hospice services to include diagnosis . Review of the facility's policy titled, admission Orders, Physician Orders . dated 5/2023, revealed, . Residents will have orders for their immediate care . 2. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE], with diagnoses including Pleural Effusion, Type 2 Diabetes Mellitus, Atrial Fibrillation, and Diastolic (Congestive) Heart Failure. Review of the Significant Change Minimum Data Set (MDS) dated [DATE], revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated that Resident #53 was cognitively intact. Resident #53 was not assessed for an indwelling…

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 the facility policy review, record review, and interviews, the facility failed to maintain Registered Nurse (RN) Coverage for 8 consecutive hours a day 7 days a week. The findings included: 1. Review of the facility policy review titled Nursing Services dated 3/2025 revealed .The community provides adequate staffing with the appropriate competencies and skills sets to provide nursing and related services to assure residents safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The community will provide licensed nursing staff 24 hours a day, 7 days a week . 2. Review of facility list of RNs revealed, the facility had a Director of Nursing (DON) and 3 additional RNs on staff. Review of the December 2024 weekend Punch Detail revealed no RN coverage for 8 consecutive hours on 12/1/2024, 12/13/2024, and 12/20/2024. Review of January 2025 weekend Punch Detail revealed no RN coverage for 8 consecutive hours on 1/17/2025 and 1/31/2025. Review of the staffing clock in and out punches for 1/17/25 through 3/3/2025,…

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 evidence of a monthly pharmacist drug regimen review for 2 of 5 sampled residents (Residents #38 and #44) reviewed for unnecessary medications. The findings include: 1. Review of the facility policy titled, Medication Regimen Reviews, dated 2/2025, revealed .Provide the Attending Physician with access or a process to document in the resident's medical record that: a. The irregularity that has been reviewed; b. Action if any that has been taken to address it; and c. Rationale for no change based upon the reported irregularity . 2.Review of medical record revealed Resident #38 was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes Mellitus, Heart Failure, Dementia, and Hypertension. Review of the Physician's orders dated 8/30/2023, revealed .RisperDAL .37.5 MG [milligram] .Inject 2 ml [milliliter] intramuscularly at bedtime every 14 day(s) related to Dementia . Review of the Physician's orders…

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 medications were properly and securely stored when medications were left unattended on 1 of 4 medication carts (medication cart #1) and the facility failed to date an opened multi-dose vial of refrigerated Tuberculin Purified Protein Derivative (aids in the detection of infection) in the medication refrigerator in 1 of 2 (East) medication rooms. The findings include: 1. Review of the facility policy titled, Storage of Medications ., dated 10/2024, revealed, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Medications requiring refrigeration must be stored in a refrigerator located in the drug room . and be labeled accordingly. Review of the facility policy titled, General Dose Preparation and Medication Administration, dated 2/2024, revealed, Facility staff should not leave medications or chemicals unattended. Facility staff should enter the date opened on the label of medications with shortened expiration dates. Review of the undated package insert 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.

Based on review of facility policy, Quarterly Payroll Based Journal (PBJ), and interview the facility failed maintain adequate staffing on the weekend for 3 of 4 Quarters in 2024. The facility failed to maintain higher than a One Star Staffing Rating for 4 of 4 Quarters. The findings include: 1. Review of the facility policy review titled Nursing Services dated 3/2025 revealed .The community provides adequate staffing with the appropriate competencies and skills sets to provide nursing and related services to assure residents safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The community will provide licensed nursing staff 24 hours a day, 7 days a week . 2. Review of the Quarterly PBJ dated January 1 - March 31, 2024, revealed the facility Triggered for One Star Staffing Rating and Excessively Low Weekend Staffing. Review of the Quarterly PBJ dated April 1 - June 30, 2024, revealed the facility Triggered for One Star Staffing Rating. Review of the Quarterly PBJ dated July 1 - September 30, 2024, revealed 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.

Based on policy review, medical record review, observation, and interview, the facility failed to promote and maintain residents' dignity when staff failed to provide a privacy bag for 2 of 6 sampled residents (Resident #9 and #17) reviewed with indwelling urinary catheters. The findings include: Review of the facility's policy titled, Indwelling Urinary Catheters, dated 5/2021, documented, .Cover the urine bag to provide privacy .Be sure the catheter tubing and drainage bag are kept off the floor . Review of the medical record, revealed Resident #9 had diagnoses of Paraplegia, Neuralgia, and Neurogenic Bladder. Review of the Physician's Order dated 12/9/2020, revealed Resident #9 had an indwelling urinary catheter. Observation in the resident's room on 6/28/2021 at 12:23 PM and 3:14 PM, and on 6/29/2021 at 8:10 AM and 10:30 AM, revealed Resident #9's urinary drainage bag was uncovered and seen in the doorway. Observation in the hallway on 6/30/2021 at 9:34 AM and 2:09 PM, revealed Resident #9 propelled herself in her wheelchair and her urinary drainage bag was uncovered. Review of…

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, employee file review, payroll time punch review, and interview, the facility failed to implement and follow their abuse policies when employee background checks were not performed for 2 of 8 staff (Registered Nurse (RN) #1 and Dietary [NAME] #1) reviewed for abuse and neglect. The findings include: The facility's Employee Background Checks (Screening) policy last approved on 5/2021, revealed .The community will not employ or otherwise engage individuals whom have been found guilty of abuse, exploitation, misappropriation of property, or mistreatment by court of law, entered into the State nurse aide registry or against the professional license they hold with the state licensure body .The facility administration and employees are committed to protecting resident from abuse by anyone including, but not necessarily limited to: facility staff .staff from other agencies providing services to our .residents .Background checks are completed .on each employee . Review of the employee personal files revealed RN #1 had a hire date of 5/21/2021. Review of the payroll…

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 properly store and maintain medications safely when 1 of 3 nurses (Licensed Practical Nurse (LPN) #2) left medications unattended and out of sight for 2 of 4 sampled residents (Resident #18 and #34) observed during medication administration. The findings include: Review of the facility's policy titled, Storage of Medication F 761, revised 4/2007, revealed .Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received .The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner . Observation outside the resident's room on 6/29/2021 at 8:30 AM, revealed LPN #2 prepared medications for Resident #18. LPN #2 placed Seroquel, Coreg, Gabapentin, Xanax, Diltiazem, finasteride, Lisinopril, Oxybutynin Chloride, Protonix, Polyethylene Glycol, Flomax, and thiamine in a open medication cup and took a Humalog KwikPen Solution into Resident #18's room. LPN #2 placed the medications on 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, Centers for Disease Control (CDC) Guidelines review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained for 1 of 1 sampled resident (Resident #17) reviewed in isolation when the resident was observed out of the room and with other residents, and when 1 of 1 nurse (Licensed Practical Nurse (LPN) #1) failed to perform hand hygiene during wound care. The findings include: Review of Centers for Disease Control and Prevention guidance titled, .Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, dated 3/29/2021, revealed .new admissions and readmissions should be placed in a 14-day quarantine . Review of the facility's policy titled, Hand Washing/Hand Hygiene F 880, dated 5/2021, revealed .This facility considers hand hygiene the primary means to prevent the spread of infections .Employees must wash their hands for at least twenty (20) seconds…

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.