Waters Of Memphis A Rehabilitation & Nursing Ctr

Based on facility policy review, 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 Registered Nurse (RN) using another RN's (RN C) Tennessee license. Imposter Nurse A was hired on 02/21/2025 and worked at the facility from 02/25/2025 to 04/23/2025. The findings include: Review of a facility policy title Abuse Program Policy dated 05/15/2023, revealed .Pre-employment Screening of Potential Employees.Prior to a new employee starting a working schedule.Obtain a copy of the state license of any individual being hired for a position.Complete a criminal background check per state statute on all new hires. Review of an Application for Employment dated 02/05/2025, revealed a Social Security Number (SSN) block was scratched out and a SSN was printed above the block that did not match the I-9 (Employment Eligibility Verification) form and a birth date that did not match the I-9 form. Review of the Background…

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 thoroughly investigate an allegation of an injury of unknown origin for 1 of 3 (Resident #1) sampled residents reviewed for abuse. The findings include: 1. Review of the facility policy titled ABUSE PREVENTION PROGRAM, dated 10/22/2022, revealed .It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property. Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings .Investigation .Any incident or allegation involving abuse or mistreatment will result in an abuse investigation .For any incident involving suspicion of abuse, neglect, or mistreatment, the Administrator or person appointed by the Administrator will gather facts prior to making a determination to conduct an abuse investigation .The final investigation report will be completed within the required timeframe allowed by Tennessee Department…

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 maintain and enhance resident's dignity and respect when 7 of 24 (Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #1, LPN #2, Unit Manager #1, Unit Manager #2, Certified Nursing Assistant (CNA) #1, CNA #4, CNA #6) staff members failed to knock before entering resident rooms, when 1 of 24 (LPN #1) staff members stood to assist Resident #45 with meals, when 1 of 24 (CNA #4) staff members did not use proper courtesy titles, and when 1 of 4 (RN #1) nurses failed to provide privacy for 1 of 5 (Resident #46) residents observed during medication administration. The findings include: 1. Review of the facility's undated policy titled, Dignity, revealed .will not refer .as feeder .Staff will not stand to feed .Privacy .Staff will knock prior to entering a resident's room .Staff will provide privacy for residents .curtain must be pulled anytime .resident needs .privacy . Review of the facility's undated policy titled, Resident Rights, revealed .The facility must care for you in a manner and environment that…

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 served under sanitary conditions when 5 of 24 staff members Certified Nurse Assistant (CNA#1, #2, #3, #4, #6) failed to perform hand hygiene during meal services. The number of meal trays served on 9/10/2023 for lunch were 73. The number of meal trays served for breakfast on 9/11/2023 were 72. The findings include: 1. Review of the facility's policy titled, Meal Service, dated 9/5/2023 revealed .It is the policy of this facility that all residents are provided adequate supervision to meet each residents nursing and personal care needs including meals service and assistance with eating .Staff providing direct care by passing meals/trays will wash their hands before serving the food .There is no bare hand contact with ready to eat foods . Review of the facility's undated policy titled, Hand Hygiene Guidelines, revealed .When hands are visibly soiled, exposure to a spore forming organism has been suspected .hands should be washed with a non-microbial or anti-microbial soap . 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, observation, and interview, the facility failed to provide effective housekeeping to maintain a sanitary environment for 3 of 53 (room [ROOM NUMBER], #230, and #307) resident rooms observed. The findings include: 1. Review of the facility's undated policy titled, GENERAL CLEANING POLICIES AND PROCEDURES RESIDENT ROOM - CLEAN revealed .To provide a clean, attractive and safe environment for residents .Clean .toilet .Dust Mop the Resident Room and Bathroom Floors .Wet Mop the Resident Room and Bathroom Floors .Clean and Sanitize Toilets .Use a separate cloth and a disinfectant to wipe every surface area of the commode including the tank .Flush the toilet as the final step to insure all cleaner is removed from the toilet bowl water . 2. Observations in room [ROOM NUMBER] on 9/10/2023 at 10:16 AM and 12:57 PM, 9/11/2023 at 7:50 AM, and 9/12/2023 at 12:35 PM, revealed a floor fan with a heavy build-up of dust particles hanging on the front and back casing of the fan against the wall at 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, facility investigation, and interview, the facility failed to ensure residents' were free from abuse for 1 of 5 (Resident #67) sampled residents reviewed for abuse. The findings include: 1. Review of the facility's policy titled, Abuse Prevention dated 1/19/2017, revealed .It is the policy of the facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property. Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings. Abuse is the willful infliction of injury, intimidation or punishment with resulting physical harm, pain, mental anguish or deprivation by an individual, including caretaker .Verbal Abuse .Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability .…

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 timely report an allegation of abuse for 1 of 5 (Resident #67) sampled residents reviewed for allegation of abuse. The findings include: 1. Review of the policy titled, Abuse Prevention Program, dated 1/19/2017, revealed .It is the policy of this facility to prevent resident abuse .The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident .Abuse Reporting .All personnel must promptly report any incident or suspected incident of resident abuse .Any alleged violations involving mistreatment, abuse .misappropriation of resident's property .MUST be reported to the Administrator and Director of Nursing .the person(s) observing an incident of resident abuse or suspecting resident abuse must IMMEDIATELY report such incidents to the Charge Nurse, regardless of time lapse since the incident occurred. The Charge…

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, review of facility investigation, and interview, the facility failed to provide documentation for an investigation of an allegation of abuse and failed to ensure a thorough investigation was completed for 1 of 5 (Resident #67) sampled residents reviewed for an allegation of abuse. The findings include: 1. Review of the facility's policy titled, Abuse Prevention, dated 1/19/2017, revealed, .It is the policy of the facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property. The following Procedures shall be implemented when an employee .becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party .All incidents will be documented, whether or not abuse occurred, was alleged or suspected .Any incident or allegation involving abuse or mistreatment will result in an abuse investigation .the Administrator or designee will investigate the allegation and obtain a copy…

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 care and services for an indwelling urinary catheter (a tube in the bladder that drains the urine) for 2 of 2 (Resident #22 and #41) sampled residents reviewed for indwelling catheters. The findings include: 1. Review of the facility's policy titled, Perineal / Incontinence Care, dated 1/1/2020, revealed .Perform hand hygiene .Put on gloves .Wash all soiled skin areas, washing from front to back, rinse and dry very well, especially between skin folds .Remove gloves .Wash hands . Review of the facility's undated policy titled, Indwelling Urinary Catheter Care, revealed .Wash hands and don gloves .Assist the resident to lie on back and expose perineal area .Soap one cloth at a time and wash genitalia using proper aseptic technique .In male resident, wash the penis first .Cleanse catheter area by washing urethral area first followed by cleansing proximal 1/3 of catheter. Change cloth as necessary .Rinse area…

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 infection control practices to prevent the spread of infection were used when 2 of 4 (Licensed Practical Nurse (LPN) #3, and LPN #5) nurses failed to perform hand hygiene and clean equipment after use during medication administration. The findings include: 1. Review of the facility's undated policy titled, Hand Hygiene Guidelines revealed .The scope of this guideline includes all interdisciplinary members .and individuals that partake in the resident's plan of care .Handwashing items .soap and water .Paper towels .Waterless Alcohol Based Agent .When hands are visibly soiled, exposure to a spore forming organism has been suspected .before and after eating, and after using the restroom hands should be washed .Allow hands to completely dry prior to applying gloves or interacting with a resident . 2. Observation in the resident's room on 9/12/2023 at 4:59 PM, revealed LPN #5 performed hand hygiene, removed Resident #32's medications from the med cart, placed the medication in a plastic medication cup,…

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 deliver meal trays to residents in a timely manner resulting in late meals. This had the potential to affect the 73 of the 78 residents who had received a tray from the Kitchen. The findings included: Review of the facility's policy titled, Resident Dining Services dated 12/6/2016, revealed .The Food and Nutrition Services department will have a process in place to assure residents receive meals in a timely manner with appropriate assistance and supervision . Observation of the halls on 7/12/2021 revealed lunch meal trays were scheduled to be delivered on the 300 Hall at 12:45 PM, on the 400 Hall at 12:50 PM, on the 100 Hall at 1:00 PM, and on the 200 Hall at 1:15 PM. Observation on 7/12/2021 revealed the first meal was delivered on the 300 Hall to a resident at 1:38 PM. The meal was 53 minutes late. Observation on the 100 Hall revealed the first meal was delivered to a resident at 2:08 PM. The meal was 1 hour and 8 minutes late. The first meal tray was delivered on the 200 Hall at 2:28 PM. The meal was 1…

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 undated food items, a dirty deep fryer, meat slicer, and mixer, inappropriate tray line serving temperatures, and 2 of 13 staff members (Certified Nursing Assistant (CNA) #1 and #2) failed to distribute and serve food in a sanitary manner during dining. This had the potential to affect the 73 of the 78 residents who had received a tray from the Kitchen. The findings include: Review of the facility's policy titled,Table Top Mixer, dated 3/26/2012, revealed .The mixer will be cleaned and sanitized after each use . Review of the facility's policy titled,Food Slicer, dated 3/26/2012, revealed .This machine must be thoroughly cleaned and sanitized after each use . Review of the facility's policy titled, Deep Fryer, dated 3/26/2012, revealed .The deep fryer will be cleaned as needed .to ensure food safety. To produce evenly cooked, perfectly browned fried products keep the oil in the deep fryer clean and clear . Observation in…

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 when dietary staff did not properly restrain hair and when food items were stored in the refrigerator and freezer uncovered, unlabeled, and undated. The facility had a census of 82 residents, with 80 of those residents receiving a tray from the kitchen. The findings include: The facility's .Dress Code policy dated 3/27/12 documented, .Food employees wear a hair covering which covers all hair completely. [NAME] guards must be used for employees with facial hair . The facility's .Cold Storage Areas policy dated 3/26/12 documented, .Date, label and properly secure all products removed from original containers . Observations in the kitchen on 6/17/19 beginning at 5:50 AM, revealed: a. Dietary Staff #1 was in the kitchen during breakfast preparation with no beard cover over his facial hair. b. Ice filled glasses stored in the freezer uncovered, unlabeled, and undated. c. Trays of pancakes, turkey sausage, and bacon uncovered, unlabeled, 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.