Gallaway Health and Rehab

Inspectors wroteBased on 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 Licensed Practical Nurse (LPN) using another LPN's (LPN C) Tennessee license.

Inspectors wroteBased on facility policy review, medical record review, email correspondence review, observation, and interview, the facility failed to protect the residents' right to be free from neglect for 3 of 14 (Resident #6, Resident #1, and Resident #12) sampled residents reviewed for abuse and neglect. Resident #6, a vulnerable, cognitively impaired, totally dependent resident who required enteral feeding (method of delivering nutrition directly into the gastrointestinal tract) for nutrition was reviewed for neglect. On 3/20/2025, the nurse documented Resident #6 had a tear on the side of the feeding port of the percutaneous endoscopic gastrostomy (PEG) tube which caused leakage of the feeding onto the bed. Resident #6 did not receive a new PEG tube until 4/7/2025, 19 days after the tear was found, which allowed for leakage of the enteral nutrition for 19 days. [...]

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to develop and implement a person-centered care plan for 1 of 3 (Resident #3) sampled residents reviewed.

Inspectors wroteBased on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, review of Employee Screening logs and employee time sheets, observation, and interview, the facility failed to ensure practices to maintain the spread of infection were maintained when 14 of 47 staff (Certified Nursing Assistant (CNA) #1, #2, #3, and #4, Licensed Practical Nurse (LPN) #1, #2, and #3, Housekeeper #1, #2, and #3 and Dietary Aide #1, #2, #3 and #4) failed to complete screening for the prevention and detection of COVID-19 prior to working on 2 of 2 days (5/25/2022 and 5/28/2022) reviewed and when 1 of 4 nurses (LPN #7) failed to properly clean and store enteral feeding syringes after use for 2 of 2 sampled residents (Resident #65 and #75) observed. This had the potential to affect the 90 residents residing in the facility.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to notify the Physician and patient representative for an allegation of abuse for 1 of 7 sampled residents (Resident #11) reviewed for abuse and the facility failed to notify patient representatives of changes in pressure ulcer status for 2 of 3 sampled residents (Resident #36 and Resident #388) reviewed for pressure ulcers/injuries.

Inspectors wroteBased on policy review, facility investigation review, medical record review, and interview, the facility failed to timely and thoroughly investigate an incident of resident-to-resident abuse for 2 of 7 sampled residents (Resident #11 and #32) reviewed for abuse.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to develop a comprehensive Care Plan for Dementia for 2 of 4 sampled residents (Resident #10 and #62) reviewed.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to ensure the completion of a discharge summary that included a recapitulation of the resident's stay, the disposition status of the resident at the time of discharge, and a post discharge plan of care for 1 of 1 sampled residents (Resident #388) reviewed for discharge.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 4 nurses (Licensed Practical Nurse (LPN) #7) followed policies and procedures for the administration of medication through a Percutaneous Endoscopic Gastrostomy (PEG) tube for 1 of 2 sampled residents (Resident #65) observed and the facility failed to ensure Physician Orders for lab were followed for 1 of 5 sampled residents (Resident #9) reviewed for lab services.

Inspectors wroteBased on Service Agreement review, policy review, observation, and interview, the facility failed to provide effective housekeeping services and maintenance services to maintain a sanitary, orderly, and comfortable environment as evidenced by missing ceiling tiles, missing grout in tiles, brown debris and brownish and black build-up on the floors and in corners of rooms, unpainted, exposed plaster, brownish build-up on window ledges, blinds, and air conditioners, air conditioners with missing pieces, discolored grout in bathrooms, worn linoleum floors exposing subflooring, gray areas on ceiling tiles, unclean, broken and rust colered resident equipment, unclean exhaust fans, brown substance and stains in sinks and on commodes, holes in walls, loose and broken tiles and base boards, bulging and crumbling dry wall, odors, gouged and scratched walls, peeling paint; [...]

Inspectors wroteBased on policy review, observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by a dirty bowl stacked in clean bowls, chipped plates, a dirty ice machine, a mound of ice in the walk-in freezer, a dirty freezer floor, staff allowing dirty dishes to come in contact with clean dishes, wet nesting of dishes [stacking of wet items, such as pans and dishes], staff touched clean dishes with dirty gloves, and staff stored personal food in a resident nutrition refrigerator. The facility had a census of 93 with 91 of those residents receiving a meal tray from the kitchen.

Inspectors wroteBased on observation and interview the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program, failed to recognize an ongoing environmental concern, and failed to provide effective housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment. The QAPI committee failed to identify the root cause of the concerns, develop appropriate plans of action, and ensure systems and processes were in place to address the concern. [...]

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 3 of 3 (Wound Care Nurse, Certified Nursing Assistant (CNA) #5, Licensed Practical Nurse (LPN) #1) staff members failed to perform proper hand hygiene during 3 of 3 (Resident #7, #21, and #41) observations of provision of care and dirty linens were left on the bathroom floor in 1 of 3 (100 Hall Central Bath) shower rooms and 1 of 42 (room [ROOM NUMBER]) resident room bathrooms.

Inspectors wroteBased on observation and interview, the facility failed to ensure 1 of 2 (100 Hall Dayroom) dayrooms, 2 of 2 (100 Hall and 200 Hall) halls, and 3 of 3 (100 hall Central Shower, Secure Unit Women's Shower, and Secure Unit Men's Shower) shower rooms were clean and sanitary.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure the safety of a resident during transfer for 1 of 6 (Resident #35) sampled residents reviewed for accidents.

Inspectors wroteBased on policy review, observation, and interview the facility failed to ensure that waste was disposed of properly for 1 of 1 dumpster observed.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to notify the physician of blood glucose (blood sugar) results for 1 of 5 (Resident #46) sampled residents.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter when nursing staff failed to keep the drainage bag off the floor for 1 of 2 (Resident #93) sampled residents reviewed for indwelling urinary catheters.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to follow physician orders related to an enteral feeding for 1 of 1 (Resident #52) sampled resident reviewed for enteral feeding.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 4 (Licensed Practical Nurse (LPN) #2) nurses properly disposed of a topical medication patch during medication administration, and failed to ensure medications were not stored past their expiration dates in 1 of 6 (100 Medication Room) medication storage areas.

Inspectors wroteBased on observations and interview, the facility failed to ensure personal care items were stored in a sanitary manner in 2 of 42 (shared bathroom of Resident #12, 15, and 87, and shared bathroom of Resident # 51 and 60) bathrooms.