Sevierville Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy reviews, medical record reviews, observations and interviews, the facility failed to follow appropriate infection practices to prevent the potential spread of infection for 8 residents (Residents #57, #54, #81, #9, #71, #30, #59, and #72) of 85 residents observed for infection control.The findings include:Review of the facility's undated policy titled, Wound Management, revealed .protocols for wound care are established .using current guidelines .for wound management .infection control practices are maintained to decrease and prevent the transmission of infection during wound care and/or dressing changes .Review of the facility's undated policy titled, Enhanced Barrier Precautions [EBP], revealed EBP are an infection control intervention designed to reduce transmission of MDRO's [Multi-Drug Resistant Organisms] in nursing homes. EBP expands upon Standard Precautions by requiring the use of gowns and gloves during specific high contact resident care activities .examples of high contact…

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 food items were labeled and stored properly in 1 of 2 freezers in the kitchen and failed to ensure a clean and sanitary milk cooler which had the potential to affect all 80 residents in the facility. The findings include: Review of the facility's undated policy titled, Sanitization, showed The food service area shall be maintained in a clean and sanitary manner .All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary .Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime .The Food Services Manager will be responsible for scheduling staff for regular cleaning of the kitchen and dining areas . Review of the facility's undated policy titled, Food…

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 ensure medical information was not visible for 1 resident (Resident #325) of 80 observed. The findings include: Review of the facility's policy titled, Resident Rights, with a revised date of 12/2016, showed .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 and confidentiality . Resident #325 was admitted to the facility on [DATE] with diagnoses including Fracture of the Left Femur, Encounter for Orthopedic Aftercare, Fall, Muscle Weakness, and Anemia. During an observation and interview on 11/6/2023 at 10:53 am, in Resident #325's room, there was a sign above the resident's bed that read, NO BLOOD PRESSURES OR BLOOD DRAWS IN THE LEFT ARM The sign was visible to anyone who entered the room.…

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 accurately code a Minimum Data Set (MDS) assessment for 1 resident (Resident #60) of 18 residents reviewed for MDS assessments. The findings include: Resident #60 was admitted to the facility on [DATE] with diagnoses including Intracapsular Fracture of Left Femur, Malignant Neoplasm of Unspecified Bronchus of Lung, and Malignant Neoplasm of Brain. Review of the Physician's Orders dated 7/25/2023, showed Resident #60 had been ordered hospice care. Review of the comprehensive care plan dated 7/25/2023, showed Resident #60 received hospice services for end-of-life care. Review of the MDS assessment dated [DATE], showed hospice care had not been captured or documented on the MDS for Resident #60. During an interview on 11/7/2023 at 2:00 PM, Chief Clinical Officer confirmed the facility failed to capture hospice on the MDS assessment. During an interview on 11/8/2023 at 10:20AM, the MDS Coordinator confirmed she failed to complete a significant…

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 resubmit a Pre-admission Screening and Resident Review (PASARR) after a new mental health diagnosis for 1 resident (Resident #61) of 7 residents reviewed for PASARR. The findings include: Resident #61 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Depression, and Anxiety. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], showed Resident #61 had an active diagnosis of .Major Depressive Disorder .Depression .Anxiety . and received antipsychotic, antidepressant medications. Review of the Level I Pre-admission Screening and Resident Review dated 9/22/2023, showed .Check any or all of the following mental health conditions that are diagnosed or suspected for the individual now or in the past .Anxiety Disorder .Depression .Should there be an exacerbation related to mental illness or a discrepancy in the reported information, a status change should be submitted [to the PASARR 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 medical record review and interview, the facility failed to follow a physician's order for 1 resident (Resident #326) of 3 residents reviewed for pressure ulcers. The findings include: Resident #326 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Sepsis, Adult Failure to Thrive, and Protein-Calorie Malnutrition. Review of Resident #326's admission skin assessment dated [DATE], showed .Redness [with] open area to Left Buttock . Review of Resident #326's baseline care plan dated 10/27/2023, showed .impaired skin integrity .open area to [left buttock] .Treatments as ordered by Physician . Review of Resident #326's physician telephone orders dated 10/27/2023, showed .[barrier cream] to bilateral buttocks BID [twice daily] . Review of the WOUND CARE PROGRESS NOTE dated 10/30/2023, showed . Wound #4: Left buttock stage 2 measuring 2 x 1 x less than 0.1 with erythema and maceration. No induration, exudate, tunneling, undermining .or odor. Treatment .apply…

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 maintain accurate and complete medical records for 1 resident (Resident #21) of 24 residents reviewed for medical records. The findings include: Resident #21 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Obsessive-Compulsive Disorder (OCD), Anxiety, Bipolar Disorder, and Depression. Review of Resident #21's Psychotropic Medication-Informed Consent form dated 2/25/2020, showed .Medication name .Depakote .why medication was prescribed: [blank] . Review of Resident #21's Psychotropic Medication-Informed Consent form dated 4/22/2022, showed .Medication name .Seroquel .Therapeutic classification: Anti-depressant .Reason why medication was prescribed: Depression . Review of Resident #21's Psychotropic Medication-Informed Consent form dated 3/28/2023, showed .Medication name .Lexapro .Therapeutic classification: [blank] .Reason why medication was prescribed: [blank] . Review of a 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 medical record review, observation, and interview, the facility failed to ensure reasonable accommodation of needs for 1 of 1 resident (Resident #33) reviewed for call light accessibility. This failure had the potential to prevent Resident #33 from calling for assistance as desired and potentially prevent Resident #33's needs from being met. Findings include: Review of the Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 12/6/2019, indicated Resident #33 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] from an acute care hospital. Resident #33's diagnoses included Cerebrovascular Accident (CVA), Hemiplegia, Dementia, Parkinson's Disease, and Contractures. Resident #33 had cognitive impairments, as evidenced by a Brief Interview for Mental Status Score (BIMS) score of 3 out of 15. Resident #33 required total assist from one to two staff members with all Activities of Daily Living (ADLs). Resident #33 had functional limitations in Range of Motion (ROM)…

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, review of facility admission packet, medical record review, and interviews, the facility failed to issue bed hold notices within 24 hours after transfer to the hospital for 2 of 27 sampled residents (Resident #27 and Resident #1). Findings include: Review of the facility policy titled, Attachment F-Bed Hold Policy, last revised March 2018, revealed, At the time the Resident is to leave the Center for a temporary stay in a hospital or for therapeutic leave, (or within 24 hours in care of an emergency transfer) the Resident/Resident Representative will be given a written copy of the Bed Hold Policy which specifies the duration of the bed-hold and may elect to hold open the Resident's room and bed until the Resident returns. At this time, the Resident/Resident Representative will indicate in writing whether the Resident desires or declines the bed hold. Review of the facility's admission packet revealed the initial notice of the bed hold policy was provided to residents upon…

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 medical record review, interviews, and review of the Hospice Cooperative Agreement, the facility failed to implement a Bowel Movement (BM) protocol and failed to ensure effective coordination of hospice care for one resident (Resident #11) out of 15 sampled residents. These failures placed Resident #11 at risk for complications related to constipation and potential fecal impaction (a large mass of dry, hard stool that can develop in the rectum due to chronic constipation). Findings include: Review of the Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/31/2019, indicated Resident #11 was receiving hospice services and had moderate cognitive impairment, as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. Review of the facility's Physician's Routine Orders for constipation, signed by the Medical Director on 1/1/2019, specified, If no BM [bowel movement] in three (3) days: Milk of Magnesia (or generic equivalent) 30 cc [cubic centimeter] by mouth every day PRN [as needed] constipation (notify MD [medical doctor] if…

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.