Ascension Living Alexian Village Tennessee

Inspectors wroteBased on facility policy review, medical record review, facility investigation review, and interviews, and corrective action plans, the facility failed to prevent significant medication errors for 1 (Resident #99) resident of 4 residents reviewed for medication administration. Registered Nurse (RN) M administered medications intended for another resident to Resident #99 in error. The medication error caused Resident #99 to develop severe hypotension (low blood pressure) resulting in hospitalization. The facility's failure to administer medications according to physician's orders resulted in HARM to Resident #99. The facility was cited at F-760 as Past Non-Compliance. No further corrective actions are required. Non-Compliance began 9/1/2025 and ended on 11/17/2025.

Inspectors wroteBased on review of facility policy, observation and interviews, the facility failed to ensure staff promoted resident dignity during dining for 1 resident (Resident #26) of 7 residents observed during dining. The findings Include:Review of the facility's undated policy titled, Tennessee Notices .Nursing Home Resident Rights, revealed .you [the resident] have the right to a dignified existence .a facility environment must treat each resident with respect and dignity and care for each resident in a manner .that promotes maintenance or enhancement of his or her quality of life .Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including History of Stroke with Hemiplegia, Aphasia, and Atrial Fibrillation. [...]

Inspectors wroteBased on review of the facility policy, review of the medical record, observation, and interview, the facility failed to ensure call lights were within reach for 1 resident (Resident #41) of 18 residents reviewed on the 800-west hallway.

Inspectors wroteBased on review of the facility's policy, review of the medical records, observations, and interviews, the facility failed to implement the comprehensive care plan for an orthotic device for 1 resident (Resident #12) and failed to update the care plan for refusal of splint use for 1 resident (Resident #39) of 5 residents reviewed for Activities of Daily Living (ADLs)/Mobility. The findings Include:Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease and Dysphagia. Review of the medical record revealed Resident #12 was transferred to the hospital on 9/11/2025, returned to the facility the same day with a new diagnosis of a fracture of the right distal fibula (bone in the lower leg toward the ankle), and the resident had a new physician's order for a tall walking boot at all times. [...]

Inspectors wroteBased on review of medical records and staff interview, the facility failed to ensure accurate documentation of a resident's meal intake which prevented the facility from determining whether the resident met the criteria for administering the ordered nutritional supplement for 1 resident (Resident #2) of 3 residents reviewed for nutrition. The findings Include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Specified Nutritional Anemia, Dysphagia, History of Subdural Hematoma, and Chronic Migraines. [...]

Inspectors wroteBased on review of the facility policy, review of the facility assessment, review of a facility document, review of resident council minutes, review of the medical record, observations, and interviews, the facility failed to ensure sufficient nursing staff as determined by the acuity of the resident population on 1 of 4 hallways observed.

Inspectors wroteBased on review of the facility policy, observation, and interviews, the facility failed to reconcile controlled medications for 3 residents (Residents #86, #13, and #67) of 8 residents reviewed for controlled substance reconciliation.

Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to ensure proper infection control practices related to hand hygiene were followed during meal service when 1 staff member failed to offer hand hygiene assistance to 1 resident (Resident #24) of #24 residents observed during meal tray distribution on 1 of 4 hallways.

Inspectors wroteBased on facility policy review, medical record review, observations and interviews, the facility failed to provide a homelike environment for 2 residents (Resident #12 and Resident #7) of 83 residents reviewed for a homelike environment.

Inspectors wroteBased on facility policy review, medical record review, observation and interview, the facility failed to develop Enhanced Barrier Precautions (EBP) on the comprehensive care plan for 3 residents (Residents #36, Resident #12 and Resident #24) of 21 residents reviewed for care plans.

Inspectors wroteBased on facility policy review, medical record review, observation and interview, the facility failed to implement Enhanced Barrier Precautions (EBP) for 3 residents (Residents #36, Resident #12, and Resident #24) of 7 residents reviewed for indwelling devices.

Inspectors wroteBased on facility policy review, Resident Assessment Instrument (RAI) Manual 3.0 review, medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #6) of 15 residents reviewed.

Inspectors wroteBased on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to ensure discontinued narcotics were removed from the inventory after discontinued for 1 resident (Resident #11) of 4 residents reviewed for narcotic administration. The facilities failure to timely remove discontinued drugs from inventory resulted in discontinued medications documented as withdrawn from stock but not accounted for in the medical record.

Inspectors wroteBased on facility policy review, medical record review, and interviews, the facility failed to ensure the medical record was complete for 1 resident (Resident #4) of 15 residents reviewed for complete medical records.

Inspectors wroteBased on facility policy review, facility investigation documentation, and interviews, the facility failed to report allegations of abuse to include injuries of unknown origin, to Adult Protective Service (APS) for 13 resident investigations (Residents #2, #19, #38, #39, #3, #37, #42, #43, #68, #69, #70, #71, and #72) of 26 resident investigations reviewed.

Inspectors wroteBased on facility policy review, observation, and interviews, the facility failed to ensure investigations were completed for allegations of abuse and injuries of unknown origin for 4 resident investigations (Resident #1, #19, #38, and #39) of 24 resident investigations reviewed for abuse including injuries of unknown origin.

Inspectors wroteBased on facility policy review, facility document review, medical record review, observation and interview, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to assess and monitor concerns with reporting allegations of abuse, injury of unknown origin, misappropriation, and neglect for 15 resident investigations (Residents #1, #2, #19, #38, #39, #3, #37, #42, #43, #64, #68, #69, #70, #71, and #72) of 26 resident investigations reviewed. The facility failed to maintain an effective QAPI program that was successful in identifying, prioritizing and implementing strategies related to ensuring incident investigations were thorough and complete as well as the reporting to all entities required. The QAPI program failed to ensure systems and processes were implemented facility wide and consistently followed by staff.

Inspectors wroteBased on interview, record review, review of the Hospitalists Discharge Summary, and review of the facility's policy, the facility failed to revise the Comprehensive Care Plan with newly identified problem areas and with new interventions for one of 35 sampled residents (Resident (R) 7). On 07/30/23, R7 was transferred to the hospital after he was discovered entrapped between his mattress and a grab bar attached to his bed. When R7 was readmitted to the facility on [DATE], his care plan was not revised to include updated interventions related to his entrapment. Additionally, while being treated at the hospital for the entrapment incident, it was discovered that R7 had a fecal impaction. [...]

Inspectors wroteBased on observation, interview, record review, and review of a facility document, the facility failed to ensure services were provided to meet acceptable professional standards for six out of six sampled residents (Resident (R) 4, R7, R8, R20, R21, and R22) reviewed for accidents, bowel monitoring, and supplemental oxygen therapy, out of a total sample of 35. On 07/30/23, R7 was found entrapped between the grab bar and mattress and sustained multiple fractures to his ribs. The nurse on duty assigned to R7 failed to complete a thorough assessment of R7 and failed to accurately report the incident to the resident's physician. Additionally, the facility failed to ensure R7 received supplemental oxygen therapy per the physician orders. [...]

Inspectors wroteBased on interviews, record reviews, and review of the facility's policy, the facility failed to ensure six of six residents (Resident (R) 4, R7, R8, R20, R21, and R22) reviewed for bowel movement monitoring received the necessary care and treatment in accordance with professional standards of practice. On 07/30/23, R7 was transferred to the hospital after becoming entrapped in between his mattress and grab bar. While receiving treatment, it was discovered that R7 had a fecal impaction. Record review revealed there were no documented bowel movements for R7 for five days leading up to the fecal impaction diagnosis. Additional record reviews revealed the facility's systemic failure of ensuring residents' bowel movements were monitored to prevent constipation. The facility's systemic failure has the potential to affect all residents who resided at the facility. [...]

Inspectors wroteBased on observations, interviews, record reviews, and review of the facility's policies, the facility failed to ensure residents were free from accidents and hazards for one of three resident (Resident (R) 7) reviewed for accidents out of a sample of 35. On 07/30/23, R7 was discovered entrapped between his low air loss mattress and the grab bar attached to his bed. The resident sustained multiple fractures to his right and left ribs. Additionally, the facility failed to complete a timely and thorough investigation into the incident. An Immediate Jeopardy was identified on 09/26/23 and was determined to exist starting on 07/30/23, in §483.25(d) F689: Accidents. The Administrator was notified on 09/26/23 at 3:45 PM of the failure to prevent accidents and hazards for R7. [...]

Inspectors wroteBased on interview, record review, and review of the facility's Administrator's and Director of Nursing's (DON) Job Descriptions, the facility failed to be administered in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident in the facility. During an abbreviated survey, five Immediate Jeopardies were identified, with the highest scope and severity (S/S) of a L and four standard level tags were cited with the highest S/S being an F. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident records were complete, and staff accurately documented care and services provided for six of six sampled residents reviewed for bowel movement monitoring and/or respiratory care (Resident (R) 4, R7, R8, R20, R21, and R22). Review of bowel monitoring documentation revealed there was inconsistent documentation by the facility staff. Additionally, the Director of Nursing (DON) assessed R7's oxygen saturations after it was discovered his oxygen concentrator was not working properly; however, the DON did not document the assessment in the resident's medical record, nor did she document any details of the event in the resident's medical record.

Inspectors wroteBased on observation, record review, interview, document review, and policy review, the facility failed to ensure there was no suspected misappropriation of property, specifically narcotic mediations for six (Residents (R) 4, R9, R10, R11, R17, and R18) from two of two agency nurses, Licensed Practical Nurse (LPN) 2 and LPN3. This had the potential for these residents to have insufficient pain medications when needed to control their pain.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to immediately notify the resident's physician when there was an accident which resulted in injury and required physician intervention for one of one resident (Resident (R) 7) reviewed for notification of accidents out of a total sample of 35. On 07/30/23 R7 was discovered entrapped between his mattress and the grab bar attached to his bed. The physician was not notified until four hours after the event. Additionally, when the nurse did notify the physician, she did not report pertinent details of the resident being entrapped. R7 was later transferred to the hospital for treatment for injuries sustained during the entrapment which included several fractured ribs.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to provide the necessary respiratory care and services consistent with professional standards of practice for one of four sampled residents (Resident (R) 7) and of one unsampled resident. On 09/26/23, R7 was not receiving supplemental oxygen as ordered, causing his oxygen saturation to drop below 90%.

Inspectors wroteBased on observations, interviews, record reviews, review of the Invacare Bed User's manual, and review of the facility's policy, the facility failed to assess and obtain consent prior to use of a grab for one of one resident sampled for bed rails (Resident (R) 7) out of a total sample of 35. The facility failed to follow the manufacturer's recommendations related to grab bars being attached to residents' beds. On 07/30/23 R7 became entrapped between the mattress and the grab bar attached to his bed sustaining injuries which included multiple rib fractures. Additionally, the facility did not complete assessments nor obtain consents prior to installing grab bars to residents' beds which had the potential to affect all 87 residents of the facility.

Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to follow infection control practices during medication administration observations for 1 of 4 nurses observed administering medications to 1 (#7) of 5 residents.