West Tennessee Post Acute

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 and ensure residents were treated with dignity and respect for 2 of 54 (Resident #25 and #33) sampled residents reviewed for resident rights. The findings include: 1. Review of the facility policy titled, Resident Rights, dated February 2021, revealed .Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .a dignified existence .be treated with respect, kindness, and dignity .privacy . 2. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Myasthenia Gravis (a chronic autoimmune disorder with weakness), Gastrostomy (a tube inserted into the stomach for the administration of nutrients or medications), Malnutrition, and Depression. Review of the admission Minimum Data Set (MDS) 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, and interview, the facility failed to follow physician's orders to meet professional standards of practice for 2 of 6 (Residents #18 and #53) sampled residents and the facility failed to revise the care plan for 1 of 6 (Resident #53) sampled residents reviewed for unnecessary medications. The findings include: 1. Review of the facility policy titled, Administering Medications, dated April 2019, revealed .Medications are administered in a safe and timely, manner and as prescribed .Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions .The following information is checked/verified .Vital signs, if necessary .The individual administering the medication initials the residents MAR [Medication Administration Record] after giving the medication . Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated March 2022, revealed .The comprehensive, person-centered care plan .describes…

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 review, medical record review, observations, and interview, the facility failed to ensure infection control practices to prevent the spread of communicable diseases when 2 of 10 staff (Certified Nursing Assistant (CNA) A and Licensed Practical Nurse (LPN) B) failed to store and use personal protective equipment (PPE) for 2 of 2 (Resident #8 and Resident #25) sampled residents reviewed for transmission based precautions (TBP) and enhanced barrier precautions (EBP). The findings include: 1. Review of the facility policy titled, Isolation-Categories of Transmission-Based Precautions, dated September 2022, revealed .Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection.Standard precautions are initiated when caring for residents at all times regardless of their suspected or confirmed infection status.The facility makes every effort to use the least restrictive approach to manage individuals with potentially communicable…

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 facility policy review, observations, and interviews the facility failed to ensure personal resident food items were labeled and dated for 2 of 2 nutrition rooms reviewed for proper food storage. The findings include: 1. Review of the facility policy titled, Foods Brought by Family/Visitors, dated 3/2022, revealed .Containers are labeled with the resident's name and date . 2. Observation in the 200-hall nutrition room on 5/7/2025 at 10:40 AM, revealed a sign on the refrigerator stating, .Please make sure all items in refrigerator and freezer Have the name, Room number, and date . The following items were found in the nutrition refrigerator unlabeled and undated: a. 1 opened 8 ounce (oz) bag of cheddar shredded cheese. b. 1 opened 24 oz bottle of chocolate syrup. c. 1 plastic zipper bag with 2 corndogs inside it. d. 1 reusable ice pack in the freezer. During an interview on 5/7/2025 at 10:43 AM, the DON confirmed that all items inside the refrigerator and freezer should be labeled and dated. 3. Observation in the 100-hall nutrition room on 5/7/2025 at 10:53 AM, revealed a…

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 complete a baseline care plan within 48 hours for 10 of 24 (Resident #5, Resident #10, Resident #12, Resident #25, Resident #26, Resident #28, Resident #34, Resident #115, Resident #116, and Resident #166) sampled residents reviewed for baseline care plans. The findings include: 1. Review of the facility policy titled, Care Plans-Baseline, revised 3/2022, revealed .A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Osteoporosis with Current Pathological Fracture, Chronic Kidney Disease, Osteoarthritis, and Spinal Stenosis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #5 was cognitively intact.…

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 protocols, medical record review, and interview, the facility failed to monitor bowel movements for 1 of 1 (Resident #115) sampled residents. The findings include: 1. Review of the Treat In Place Protocols/Advanced Nursing Protocols, signed by the Medical Director on 4/13/2025, revealed .The facility will provide assessment and early recognition of residents experiencing .change of condition .CONSTIPATION AND BOWEL PROTOCOL .check for bowel sounds .SET ONE: If No BM [Bowel Movement] for 3 days, give: Lactulose [used for constipation] .x1dose .STEP TWO: IF No BM, on the following day (4th day) Listen for bowel sounds: notify MD [Medical Doctor] if NO bowel sounds .Give Dulcolax [used for constipation] supp [suppository] .X1 AND Lactulose .every 6 hours for 24 hours or until .bowel movement .Bowel Protocol for Constipation For no BM in 3 days, Lactulose [used for constipation] . 2. Review of the medical record revealed Resident #115 was admitted to the facility on [DATE], and readmitted…

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 for oxygen for 1 of 3 (Resident #25) sampled residents reviewed for respiratory care. The findings include: 1. Review of the facility policy titled, Oxygen Administration, dated October 2010, revealed .Verify there is a physician's order for this procedure .Review the resident's care plan . Review of the facility policy titled, .Medication and Treatment Orders, dated July 2016, revealed .Medications shall be administered upon the written order of a person .authorized to prescribe .following treat in place/standing orders . 2. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Pulmonary Edema, End Stage Renal Disease, Dependance of Dialysis, and Anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13…

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 Code of Federal Regulations, Title 42, Chapter IV, Subchapter G Part 483 review, medical record review, observation, and interview the facility failed to ensure 2 of 5 nurses (Registered Nurse (RN) G and Licensed Practical Nurse (LPN) E) administered medications with a medication error rate of less than 5 percent (%). A total of 3 errors were observed out of 27 opportunities, resulting in a medication error rate of 11.11%. The findings include: 1. Review of the Code of Federal Regulations Title 42, Chapter IV, Subchapter G, Part 483 dated 5/12/2025, revealed, . Standard: Drug administration. The facility must have an organized system for drug administration that identifies each drug up to the point of administration. The system must assure that . All drugs are administered in compliance with the physician's orders .All drugs, including those that are self-administered, are administered without error .Drug administration errors and adverse drug reactions are recorded and reported immediately to a…

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 medications were properly stored when medications were found unsecured and unattended in 3 of 56 (Residents #26, #365, and #366) resident occupied rooms and when 1 of 4 (Cart B200) medication carts was found unlocked and unsecured. The findings include: 1. Review of the facility policy titled, Medication Labeling and Storage, dated 2/2023 revealed The facility stores all medications and biologicals in locked compartments .Only authorized personnel have access to keys . 2. Review of medical record revealed Resident #26 was admitted on [DATE], with diagnoses including Paraplegia, Pressure Ulcer of Left Hip, Diabetes, and Acute Kidney Failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #26 was cognitively intact. Review of the Physician's Orders dated 5/5/2025, revealed .Nystatin External Powder…

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, observations, and interviews, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 5 nurses Registered Nurse ((RN) A) failed to wear eye protection while administering enteral medications in a Droplet isolation room, and 1 of 5 nurses (RN G) failed to perform hand hygiene and change gloves prior to administering eye drops to a resident. The findings include: 1. Review of the facility policy titled, Isolation Categories of Transmission Based Precautions, dated 9/2022, revealed, .Transmission-based precautions are initiated when a resident .is at risk of transmitting the infection to other residents .Droplet precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets .that can be generated by the individual coughing, sneezing, talking .Gloves, gown and goggles are worn if there is a risk of spraying respiratory secretions . 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.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 6 staff members (Registered Nurse (RN A) left medications unattended at the resident's bedside, and when unused medications were taped and placed back into the medication cart, and when 1 of 6 medication carts was left unlocked and unattended during medication administration. The findings include: 1. Review of the facility's policy titled Medication Administration: Medication, Controlled and Biological Storage . dated 9/5/2023, revealed .It is the policy of this facility to ensure all medications housed on our premises shall be stored in the .medication rooms according .segregation and security .The medications shall be labeled in accordance with accepted professional principles to include .during a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area or cart .Unused medications: These medications are destroyed . 2. During an observation during medication…

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 practices to prevent the potential spread of infection were maintained when a Registered Nurse (RN A) failed to perform hand hygiene during medication administration and failed to wear Personal Protective Equipment (PPE) for 1 of 2 sampled residents (Resident #211) reviewed for enhanced barrier precautions. The findings include: 1. Review of the facility's policy titled, Medication Administration dated 8/4/2023, revealed .Medications administered via [by way of] feeding tube: Follow infection control precautions and related techniques to minimize the risks of contamination . Review of the facility's policy titled, Transmission Based Precautions, dated 4/1/2024, revealed .It is our policy to take appropriate precautions to prevent transmission of infectious agents. An order for enhanced barrier precautions shall be obtained for residents with any . feeding tubes .even if the resident is not known to be…

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.