Asbury Place Kingsport

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to obtain a timely signature on the required Notice of Medicare Non-Coverage (NOMNC) for 1 resident (Resident #56) of 3 residents reviewed for beneficiary notification. The findings include:Review of the facility's undated policy titled, Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS [Centers for Medicaid and Medicare Services]-10123, revealed .The NOMNC must be delivered at least two calendar days before Medicare covered services end .The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed .Review of the medical record revealed Resident # 56 was admitted to the facility on [DATE] with diagnoses including Nontraumatic Subarachnoid Hemorrhage, Muscle Weakness, Metabolic Encephalopathy, and Emphysema. Review of a Social Service Note…

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, pharmacy record review, observation, and interview, the facility failed to administer a prophylactic antibiotic [medication used to treat a bacterial infection, in prophylactic use it is used to help decrease the risk for a recurring bacterial infection] as ordered by the Physician for 1 resident (Resident #8) of 15 residents reviewed for medications.The findings include: Review of the facility's undated policy titled, Medication Administration Guidelines, revealed .Verify that the name & [and] dose of the medication are correct .Verify each medication against the MAR [Medication Administration Record] .Sign MAR immediately after administering the medications . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Diabetes Mellitus, and Hypertensive Heart Disease. Further review revealed Resident #8 was hospitalized from [DATE]-[DATE], and from 1/1/2026-1/8/2026. Review of 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.

Based on facility policy review, observation, and interview, the facility failed to ensure expired over-the-counter medications, intravenous (IV) catheters, syringes, blood collection tubes (vacuum-sealed tubes used for collecting, transporting, and processing blood samples for laboratory analysis), and sterile water vials were discarded and not available for resident use, failed to ensure an insulin pen was labeled with the resident's name, and failed to ensure wound care supplies were stored unopened in 1 medication cart of 2 medication carts and 1 medication room of 2 medication rooms observed for medication storage. The findings include:Review of the facility's undated policy titled, MEDICATION STORAGE IN THE FACILITY, revealed .Medications and biological are stored safely, securely, and properly following the manufacturer or supplier recommendations .Outdated, contaminated, or deteriorated drugs and those in containers, which are .without secure closures will be immediately withdrawn from stock .During an observation of the Willow/Dogwood medication cart on 3/31/2026 at 8:47…

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 interviews, the facility failed to maintain an accurate and complete medical record for 1 resident (Resident #8) of 15 medical records reviewed. The findings include:Review of the facility's undated policy titled, Medication Administration Guidelines, revealed .Verify that the name & [and] dose of the medication are correct .Verify each medication against the MAR [Medication Administration Record] .Sign MAR immediately after administering the medications . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Diabetes Mellitus, and Hypertensive Heart Disease. Further review revealed Resident #8 was hospitalized from [DATE]-[DATE], and from 1/1/2026-1/8/2026. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 0 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had 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, facility investigation review, and interview the facility failed to submit a 5 day follow up of the facility's investigation to the State Survey agency for 1 resident (Resident #1) of 4 residents reviewed. The findings include: Review of the facility's Policy titled, Resident Rights-Abuse and Crimes against, revised 6/16/2023 showed .all alleged violations .are reported .to the .state agency responsible for surveying/licensing the facility . continued review showed no procedure or process for submitting a 5 day follow up investigation, after the initial report to the State Survey agency. Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Difficulty in Walking, and Cognitive Communication Deficit, the resident discharged to the hospital on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS)…

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, observation, and interview, the facility failed to ensure expired food items were discarded and failed to ensure food was properly stored in a walk-in freezer in 1 of 2 kitchens which had the potential to affect 29 residents. The findings include: Review of the facility policy titled, Sanitation & [and] Infection Control Receiving & Storage, dated 1/2016, showed .Proper storage procedures will be utilized for all dry and refrigerated food storage .All items are dated when received to ensure correct product rotation .Items are stored a minimum of 18 inches from the ceiling . Review of the facility policy titled, Sanitation & Infection Control Labeling & Dating, dated 1/2016, showed .All foods will be appropriately wrapped, labeled and dated on food storage guidelines. Appropriate storage .and food rotation procedures are followed . All foods are labeled, dated, and securely covered and use-by dates are monitored and followed. RTE [Ready To Eat] products once opened have a 7-day shelf life .All products are rotated using the first-in, first-out…

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, observation, and interview, the facility failed to ensure garbage and refuse was properly contained in 1 of 4 dumpsters. The findings include: Review of facility policy titled, Sanitation and Infection Control Garbage & [and] Refuse Disposal, dated 1/2016, showed .All garbage, refuse, glass, tin cans, cardboard, paper .generated within the Food and Nutrition Services department shall be disposed of in a sanitary manner . All items shall be disposed of in appropriate dumpster, food/medical waste versus recyclable materials .All parties utilizing the dumpsters for waste to prevent harborage and feeding of pests .All parties utilizing the dumpsters for waste and/ or recycling purposes are responsible for maintaining the area by ensuring that the dumpster lids are closed and the area around the dumpster is free of waste . During an observation and interview with the Certified Dietary Manager on 5/22/2023 at 11:00AM, showed 1 dumpster had a large trash bag of refuse extending ¾ out of the top of the dumpster. The Certified Dietary Manager confirmed 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 facility policy review, observation, and interview, the facility failed to ensure appropriate hand hygiene practices were followed during meal service on 1 of 3 hallways observed during meal service. Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 1/1/2017, showed .handwashing/hand hygiene as the single most important means of preventing the spread of infection .All personnel will follow the handwashing procedure to prevent the spread of infection and disease to other personnel, residents, and visitors. Employees will perform appropriate handwashing procedures using antimicrobial or non-antimicrobial soap and water under the following conditions and as additionally needed .When to wash hands .Before and after each resident contact .Before handling food tray or preparing food . During an observation and interview on 5/22/2023 at 12:30 PM, Certified Nursing Assistant (CNA) #2 was observed retrieving a meal tray from a meal cart without performing hand hygiene, entered a resident room, set up the meal tray for the resident, positioned the resident'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 facility policy review, observation, and interview, the facility failed to ensure kitchen equipment was maintained in good repair in 1 of 2 kitchens. The findings include: Review of the facility policy titled, Manual Can Opener Maintenance, dated 1/2017, showed .Can Opener Blade and Gears must be checked for wear quarterly .Look for wear on blade or dulling of blade and wear on gears .if wear on blade is present, blade should be replaced . During an observation and interview with the Certified Dietary Manager on 5/22/2023 at 11:00 AM, showed a can opener on the kitchen preparation table with a frayed blade which had the potential to introduce metal shards into the canned food. The Certified Dietary Manager confirmed the can opener blade was frayed and used for resident food preparation.

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 ensure 1 resident (#190) was free from significant medication errors of 5 residents observed for medication administration. The findings include: Review of the facility policy Medication Administration, undated, revealed .Medications are administered in accordance with written orders of the attending physician . Medical record review revealed Resident #190 was admitted to the facility on [DATE] with diagnoses including Fracture Right Hip, Pulmonary Emboli, and Hypertension. Medical record review of the Physician's Order dated 1/7/20 for Resident #190 revealed, .Eliquis [medication used to thin the blood] 5mg [milligram] 1 TABLET oral Two Times Daily starting 1/7/20 . Observation of medication administration on 1/7/20 at 7:40 AM, on the Magnolia Hallway, revealed Licensed Practical Nurse (LPN) #1 administering medications to Resident #190. Continued observation revealed the LPN administered Eliquis 5mg 2…

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.