Nhc Healthcare, Farragut

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 and obtain a physician's order for medication self-administration for 1 resident (Resident #128) of 1 resident reviewed for self-administration of medication. The findings include:Review of the facility's policy titled, Self-Administration of Medications, dated 2/2025, revealed, a physician order should be obtained then an assessment is conducted by a member of the interdisciplinary team of the resident's cognitive .physical, and visual ability to carry out this responsibility .a member of the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis .the results of the interdisciplinary team member's assessment of resident skills .are recorded in the resident's medical record .Review of the medical record revealed Resident #128 was admitted to the facility on [DATE] with diagnoses including Diabetes, Heart Failure, and Lung…

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, Lippincott Nursing Center website review, medical record review, and interviews, the facility failed to ensure basic nursing standards for the rights of medication administration were followed for 1 resident (Resident #12) of 7 residents reviewed for insulin administration.The findings include:Review of the facility's policy titled, Specific Medication Administration Procedures, dated 2/25/2025, revealed .Review medications for accuracy .Check MAR/TAR [Medication Administration Record/ Treatment Administration Record] for order .Prior to administering medication .check the label [medication label] against the order [Physician's order] on the MAR .Review of the Lippincott Nursing Center Website resource of the Nursing Drug Handbook dated 2025- 2026, revealed .Medication Errors in Nursing .As a final step in the administration process .and the .defense against medication errors .nurses must follow the rights of medication administration .Right Patient .Right medication .Right…

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 maintain a sanitary kitchen environment by failing to properly store opened food items that were observed in 1 of 1 dry storage room and 1 of 1 reach in freezer with the potential to affect 89 of 91 residents. The findings include: Review of the facility's policy titled, Safety & Sanitation Best Practice Guidelines, dated 11/2017, showed .REFRIGERATOR AND FREEZER STORAGE .Foods will be stored .Clearly labeled with the contents and the use by date .DRY STORAGE .if opened .should be clearly labeled . During a tour of the kitchen on 9/11/2023 at 10:47 AM, with the Dietary Manager and the Regional Dietician, the following items were found. In the dry storage: 1- 3.9 liter bottle of olive oil, 1/8 full, opened, and unlabeled 1- 16-ounce jar of low sodium chicken base, full, opened, and unlabeled In the reach-in freezer: 1- 5 pound bag sweet potato fries, 1/2 full, opened, and unlabeled During an interview on 9/11/2023 at 11:03 AM, the Dietary Manager confirmed the olive oil, chicken base and sweet potato…

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 record review, observation and interview, the facility failed to provide services necessary to maintain a sanitary, orderly, and comfortable interior for 5 residents (Residents #10, #217, #226, #324 and #318) of 91 residents reviewed for environment. The findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses including Hypothyroidism, History of Falling and Depression and resided in room [ROOM NUMBER] bed A. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #10 had moderate cognitive impairment. Resident #217 was admitted to the facility on [DATE], with diagnoses including History of Falling, Chronic Obstructive Pulmonary Disease and Type 2 Diabetes Mellitus and resided in room [ROOM NUMBER] bed B. Review of an entry MDS assessment dated [DATE] showed Resident #217 was cognitively intact. During an observation and interview on 9/11/2023 at 11:48 AM, in room [ROOM NUMBER], a portable air conditioning unit was positioned on the floor by 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 facility policy review, record review, observation and interview, the facility failed to provide a summary of the baseline care plan to 1 resident (Resident #218) of 24 residents reviewed for baseline care plans. The findings include: Review of the facility's policy titled, Nursing Services, dated 2/2023, showed .A baseline care plan is developed to address the immediate needs .within 48 hours of .admission .summary of the baseline care plan will be shared with the patient and the representative . Resident #218 was admitted to the facility on [DATE] with diagnoses including Traumatic Subdural Hemorrhage, History of Falling and Depression. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #218 was cognitively intact. During an interview on 9/12/2023 at 8:19 AM, Resident #218 stated she did not receive a summary of her baseline care plan. Record review showed no documentation Resident #218 received a summary of her baseline care plan. During an interview on 9/13/2023…

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 implement the comprehensive care plan for 1 resident (Resident #45) related to wounds of 3 residents reviewed for wounds. The findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses including, Left Femur Fracture, History of Falling, Dementia, and Pressure Induced Deep Tissue Damage of Left Heel. Review of a Physician Order dated 8/15/2023, showed .PATIENT TO HAVE L [LEFT] HEEL PROTECTOR ON WHEN IN BED . Review of Resident #45's comprehensive care plan dated 8/15/2023, showed .PATIENT TO HAVE L HEEL PROTECTOR ON WHEN IN BED . During an observation on 9/13/2023 at 10:25 AM, Resident #45 was lying in bed and the left heel protector was not in place. During an interview on 9/13/2023 at 10:26 AM, the wound care Licensed Practical Nurse confirmed Resident #45 did not have the left heel protector in place I'm not sure why but I will find out. During an interview on 9/13/2023 at 3:30 PM, 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 facility policy review, medical record review, and interview the facility failed to update a comprehensive care plan to include an identified need for 1 resident (Resident #9) out of 22 residents reviewed. The findings include: Review of the facility's policy titled, Comprehensive Care Plan, dated 2/2023, showed .Decision making/planning is based on identified needs/problems and builds on patient strengths while taking into account the patient's preferences . Resident #9 was admitted to the facility on [DATE] with diagnoses including Moderate Protein-Malnutrition, Fracture Left Humerus, Mass Upper Right Limb, and Osteoporosis. Review of Resident #9's comprehensive care plan dated 8/16/2023 showed no prompted toileting had been added as an intervention for bladder incontinence due to bladder leakage. Review of Resident #9's admission Minimum Data Set (MDS) assessment dated [DATE] showed resident had a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact 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 record review, observation, and interview, the facility failed to follow a physician's order for a pressure reducing device for 1 resident (Resident #45) of 3 residents reviewed for pressure ulcers. The findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses including Fracture of Left Femur, Presence of a Left Artificial Hip Joint, Dementia, Pressure-Induced Deep Tissue Damage of the Left Heel, and Encounter for Palliative Care. Review of the Braden Scale assessment dated [DATE], showed a score of 16, which indicated Resident #45 was at risk for skin breakdown. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score was 4, which indicated Resident #45 had severe cognitive impairment, required limited one person assistance with bed mobility, had risk of pressure ulcers present, had the presence of an unstageable deep tissue injury (DTI), utilized a pressure reducing device, and had received 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 facility policy review, observation and interview, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, for 1 resident (Resident #40) of 3 residents reviewed for wound care. The findings include: Resident #40 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Long Term (current) Use of Anticoagulants, Other Giant Cell Arteritis, Long Term (current) Use of Systemic Steroids, Peripheral Vascular Disease, and Acquired Absence of Other Right Toes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident scored a 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. Further review showed Resident # 40 had a pressure reducing device on the chair and bed and the resident had venous and arterial ulcers. Review of Resident #40's comprehensive care plan dated [DATE], showed .Right lower extremity wounds cleanse right lateral foot 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 medical record review and interview the facility failed to provide scheduled/prompted toileting, a Bowel and Bladder need identified for 1 resident (Resident #9) out of 22 residents reviewed. The findings include: Resident #9 was admitted to the facility on [DATE] with diagnoses including Moderate Protein-Malnutrition, Fracture Left Humerus, Mass Upper Right Limb, and Osteoporosis. Review of Resident #9's Comprehensive Care Plan dated 8/16/2023, showed no prompted toileting had been added as an intervention for bladder incontinence due to bladder leakage. Review of Resident #9's admission Minimum Data Set (MDS) assessment dated [DATE] showed resident had a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact and was frequently incontinent of bowel and bladder. Review of Resident #9's Bowel and Bladder assessment dated [DATE], showed the resident is not always incontinent of bowel and bladder, a score of 10 indicated resident was a candidate 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 review of the facility's Nurse Aide Training (NAT) program, review of work schedules and interview, the facility failed to ensure 1 of 4 Nurse Aides (NA) #1 was removed from the working schedule and not allowed to perform the duties of a Certified Nursing Assistant (CNA) after 120 days of taking the NAT program. The findings include: Review of the facility's working schedule for the months of 8/2023 and 9/2023 showed NA #1 had worked as a NA and performed direct resident care. During an interview on 9/12/2023 at 10:22 AM, NA #1 stated he had worked at the facility for 5 months, continued to provide direct resident care, and took the certification test on 9/12/2023. During an interview on 9/13/2023 at 7:48 AM, the NAT Instructor stated NA #1 had taken the NA certification examination on 9/12/2023 and had passed. The NAT Instructor stated NA #1 had worked at the facility providing direct resident care since 4/3/2023. During an interview on 9/13/2023 at 8:25 AM, the Registered Nurse Unit Manager stated NA…

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 dispose of garbage and refuse properly in 1 of 2 dumpsters. The findings include: Review of the facility's policy titled, Safety & Sanitation Best Practice Guidelines, dated 11/2017, showed .WASTE MANAGEMENT .Receptacles and waste handling units shall be kept covered .after they are filled .Dumpsters will be checked routinely for cleanliness .debris .Doors are to be kept closed except during use . An observation of 2 dumpsters on 9/11/2023 at 11:05 AM, with the Dietary Manager and the Regional Dietician, showed the left dumpster was full, contained food containers and was uncovered. Food containers were found on the ground around the dumpster attracting flies and bees. During an interview on 9/11/2023 at 11:10 AM, the Dietary Manager confirmed the area around the dumpster was littered with food containers and the left dumpster was not covered, which allowed pests to enter, and was not a sanitary environment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to maintain an accurate medical record for 1 Resident (#6) of 19 residents reviewed. The findings include: Resident #6 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Long Term Current Use of Insulin, Hypertension, Dementia, and Major Depressive Disorder. Review of Resident #6's physicians orders dated 8/17/2023, showed fasting blood sugar before meals and at bedtime and contact the provider (Physician or Nurse Practitioner) for blood sugar less than 70 and greater than 400. Review of the medication administration record (MAR) for [DATE] showed an entry on 8/18/2023, .Blood Sugar .424 .called [Nurse Practitioner] .and order received to give 12 units lispro insulin .and retest in 2 hr [hour] . Continued review showed no documentation the 12 units of insulin had been administered or the retest of the blood sugar (BS) had been documented on the MAR. During an interview on 9/13/2023 at 4:43 PM,…

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 medications were administered in a timely manner and in accordance to professional nursing standards for 6 of 10 residents (Resident #56, #63, #72, #3, and #349, #191) reviewed for unnecessary medications. The findings include: Review of the facility policy titled, PREPARATION AND GENERAL GUIDELINES, dated 6/2016, showed Medications are administered as prescribed in accordance with good nursing principles and practices .Medications are administered within 60 minutes before or after scheduled time. Unless otherwise specified by the prescriber . Resident #56 was admitted to the facility on [DATE] with diagnosis of Acute Respiratory Failure with Hypoxia, Chronic Kidney Disease Stage 3, Anxiety Disorder, Congestive Heart Failure, Paroxysmal Atrial Fibrillation, and Rheumatoid Arthritis. Review of Resident Orders dated 1/1/2020 - 1/29/2020 showed Resident #56 was ordered the following: *Buspirone (an anti-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.