Holston Rehabilitation and Care Center

Inspectors wroteBased on facility policy review, medical record review, facility investigation review, hospital record review, and interview, the facility failed to provide an environment that was as free of accident hazards as possible and provide adequate supervision to prevent accidents for 1 of 5 (Resident #166) residents reviewed for falls. Resident #166 had an unwitnessed fall, nursing staff failed to report the fall to the physician resulting in a 9-day delay in evaluation and Resident #166 was later diagnosed with a left hip fracture. The facility's failure resulted in actual Harm for Resident #166.

Inspectors wroteBased on facility policy review, observations, and interviews, the facility failed to ensure the dumpster area was maintained in a clean and sanitary condition and garbage and refuse were properly contained in 3 of 3 dumpsters.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure appropriate Personal Protective Equipment (PPE) was donned for 2 residents (Resident # 25 and #37) of 25 residents observed for Enhanced Barrier Precautions (EBP) and the facility failed to wear face coverings during a COVID-19 outbreak on 5 of 5 hallways of 1 of 2 shifts.

Inspectors wroteBased on facility policy review, medical record review, facility investigation review, personal file review, and interview, the facility failed to protect a resident's rights to be free from misappropriation and/or exploitation when money totaling $23.11 was taken from 1 resident (Resident #43) of 22 residents reviewed for misappropriation.

Inspectors wroteBased on review of facility policy, review of medical record, and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASARR) timely after a new mental health diagnosis was added for 1 resident (Resident #10) of 8 residents reviewed for PASARR.

Inspectors wroteBased facility policy review, medical record review, observation, and interview, the facility failed to implement care plan interventions related to blood glucose checks for 1 resident (Resident #109) and falls for 2 residents (Resident #138 and #166) of 25 residents reviewed for care plans.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview the facility failed to revise the care plan for 2 residents (Resident #25 and Resident #100) of 25 residents reviewed for care plans.

Inspectors wroteBased on review of facility policy, review of medical records, and interviews, the facility failed to follow the Physician's Orders for blood glucose monitoring for 1 resident (Resident #109) of 5 residents reviewed for blood glucose monitoring.

Inspectors wroteBased on review of facility policy, review of the medical record, observation, and interview, the facility failed to follow a physician's order for oxygen therapy for 1 resident (Resident #56) of 5 residents reviewed for oxygen therapy and failed to document CPAP/BIPAP (Continuous Positive Airway Pressure/Bilevel Positive Airway Pressure) (machine that provides continuous positive airway pressure device used to keep the airway open during sleep], BIPAP [machine that provides bi-level positive airway pressure to keep the airway open during sleep) care for 1 resident (Resident #72) of 8 residents reviewed for CPAP/BIPAP.

Inspectors wroteBased on facility policy review, observation, and interview the facility failed to maintain sanitary kitchen equipment which had the potential to effect 120 of the 122 residents in the facility.

Inspectors wroteBased on facility policy review, medical record review, observation and interview, the facility failed to ensure medical information was not visible for 3 residents (#1, #27, and #31) of 122 residents observed and failed to ensure 1 resident (Resident #47) was assisted to the smoking area of 7 residents reviewed for smoking.

Inspectors wroteResident #1 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Hemiplegia, Asthma, Depression, Dementia, Atrial Fibrillation, Hypertension, and Peripheral Vascular Disease. Review of a quarterly MDS assessment dated [DATE], showed Resident #1 had an active diagnosis of Septicemia (infection of the bloodstream). During an interview on 3/3/2024 at 12:30 PM, LPN #3 stated Resident #1 was not receiving antibiotics for Septicemia. During an interview on 3/4/2024 at 10:30 AM, the MDS Coordinator stated Resident #1 was inaccurately coded on the MDS dated [DATE] for the active Septicemia diagnosis. During an interview on 3/4/2024 at 3:20 PM, the DON stated Resident #1 had not been treated for Septicemia. [...]

Inspectors wroteResident #100 was admitted to the facility on [DATE] with diagnoses including Hemiplegia following a Cerebral Infarction, Aphasia, and Nontraumatic Intracerebral Hemorrhage. Review of an Activities Initial Review assessment dated [DATE], showed Resident #100 had no preference to participate in spiritual activities, and the resident did not wish to have clergy visits. Review of an admission MDS assessment dated [DATE], showed Resident #100 was severely impaired for decision making. Review of Resident #100's comprehensive care plan dated 1/9/2024, showed .spiritual distress .consult clergy as needed .determine resident's religion affiliation .determine spiritual beliefs regarding death .encourage [the] resident to continue to study spiritual beliefs . [...]

Inspectors wroteBased on facility policy review, medical record review and interviews, the facility failed to include the resident or resident's representative in the care planning process for 1 resident (Resident #106) of 28 residents reviewed for care planning.

Inspectors wroteBased on facility policy review, medical record review, observations, and interview the facility failed to provide a safe environment by leaving medications unsecured at the bedside for 1 resident (Resident #419) of 28 residents observed.

Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to accurately transcribe an admission order for 1 resident (Resident #48) of 3 residents reviewed for admission orders and the facility failed to ensure admission assessments were accurate for 1 resident (Resident #364) of 28 sampled residents.

Inspectors wroteBased on facility contract review, facility policy review, medical record review, and interview, the facility failed to ensure a coordinated plan of care with the hospice provider was available in the medical record for 1 (Resident #60) of 4 residents reviewed for hospice.

Inspectors wroteBased on facility policy review, medical record review, observations, and interviews the facility failed to assist 4 residents (Residents #20, #75, #614, and #39) with hand hygiene before meals on 1 of 5 hallways observed for meal service.

Inspectors wroteBased on review of facility policy, medical record review, and interview, the facility failed to ensure physician orders were followed for 1 resident (Resident #48) of 28 residents reviewed.

Inspectors wroteBased on facility policy review, medical record review, review of the facility investigation and interview, the facility failed to ensure facility staff did not assume the possession and control of a resident's personal property, for 1 resident (Resident #3) of 5 residents reviewed.

Inspectors wroteBased on facility policy review, record review, observations, and family and staff interviews, the facility failed to ensure a resident and representative participated in the development and implementation of a person-centered plan of care for 1 of 12 residents (Resident #336), which had the potential to result in unmet care needs.

Inspectors wroteBased on facility policy review, record review, observation, and resident and staff interview the facility failed to follow physician's orders for wound care for 1 resident of 3 residents reviewed for wounds (Resident #286) which resulted in an unmet care need. The facility failed to update the monthly physician's recapitulation orders to reflect a change in the resident's code status for 2 of 32 sampled residents (Resident #30 and #125), which had the potential to result in the facility not following the resident's preference in code status.

Inspectors wroteBased on medical record review, and staff interview, the facility failed to obtain laboratory services as ordered by the physician for 1 of 5 residents sampled (Resident #103), which had the potential to result in unmet care needs.