Obion County Nursing Home

Inspectors wroteBased on facility policy review, Board of Examiners of Nursing Home Administrators (BENHA) review, facility benefit plan review, employee file review, employee W-2 form review, employee check stub review, timeclock punch detail review, bookkeeping system screenshot review, Certified Public Accounting (CPA) Firm documentation review, facility email review and interview, Administration failed to ensure appropriate checks and balances were implemented to prevent financial mismanagement of the payroll system and the facility checking account. Administration failed to ensure Medicare and Medicaid payments, insurance payments and private payments from residents, were protected from cash out by facility staff members when payroll, which was previously outsourced to another entity, was brought back into the facility on 1/1/2024. [...]

Inspectors wroteBased on facility policy review, Board of Examiners of Nursing Home Administrators (BENHA) review, Governing Board/Body Meeting minutes review, Certified Public Accounting (CPA) Firm documentation review, and facility email review, the Governing Board/Body failed to provide oversight and implement appropriate checks and balances to prevent financial mismanagement of the payroll system and the facility bank account into which payments, including Medicare, Medicaid, insurance, and private payments from residents were deposited. The Governing Board/Body failed to appoint an Administrator who was held accountable to responsibly manage the facility and the payroll system and communicate all aspects of the facility's financial operations to the Governing Board/Body. [...]

Inspectors wroteBased on policy review, medical record review, facility video review, facility investigation review, observation, and interview, the facility failed to ensure staff followed the facility policy for a resident transfer and assessment of an injury after a transfer for 1 of 3 (Resident #1) sampled residents reviewed for accident hazards. On 6/11/2025, Resident #1, a cognitively impaired vulnerable resident, who required 2-person assistance with transfers, was transferred from the bed into the shower chair, and from the shower chair into the wheelchair, using her arms instead of the mechanical lift, by 2 Certified Nursing Assistants (CNA) A and B. Approximately 3 hours later, CNA B reported the injury to Licensed Practical Nurse (LPN) F, who was observed to assess Resident #1's injury on facility video footage, and failed to report the incident to Administration or document the assessment. [...]

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to perform practices to prevent the potential spread of infections during medication administration and pressure ulcer care when 3 of 3 (Licensed Practical Nurse (LPN) A, B, and C) staff members failed to perform hand hygiene, administered contaminated medications and performed pressure ulcer care with contaminated gloves.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure residents were free of physical restraints for 1 of 1 (Resident #31) sampled residents reviewed for restraints.

Inspectors wroteBased on the policy review, medical record review, observation, and interview, the facility failed to identify, evaluate and analyze the cause to eliminate the risk of accident hazards for 1 of 2 (Resident #12) sampled residents reviewed for accident hazards, when on 12/27/2024 Resident #12 fell from a lift device and sustained a fracture of the left humerus.

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 obtain a physician's order, and provide care and services for the indwelling urinary catheter for 1 of 3 (Resident #32) sampled residents reviewed for indwelling urinary catheters.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to provide ongoing communication of care with the dialysis center and failed to assess and monitor the dialysis site for any redness, swelling and/or signs of infection for 1 of 1 (Resident #25) sampled residents reviewed for dialysis.

Inspectors wroteBased on facility documentation review, observation, and interview, the facility failed to ensure posted staffing information was accurate for 24 of 33 days (2/13/2025, 2/14/2025, 2/17/2025, 2/19/2025, 2/20/2025, 2/21/2025, 2/24/2025, 2/25/2025, 2/26/2025, 2/27/2025, 2/28/2025, 3/3/2025, 3/4/2025, 3/5/2025, 3/6/2025, 3/7/2025, 3/8/2025, 3/9/2025, 3/10/2025, 3/11/2025, 3/12/2025, 3/13/2025, 3/14/2025 and 3/19/2025) reviewed during the survey.

Inspectors wroteBased on policy review, medical record review, observation and interview, the facility failed to ensure 2 of 3 nurses (Licensed Practical Nurse (LPN) B and LPN C) administered medications with a medication error rate of less than 5 % (percent). A total of 2 errors were observed out of 25 opportunities, resulting in a med error rate of 8%.

Inspectors wroteBased on review of the Blood Glucose Monitoring User Guide, policy review, job description review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when multi-use blood glucose meters were not cleaned and disinfected to prevent cross-contamination of bloodborne pathogens for 4 of 14 sampled residents (Residents #3, #9, #38, and #49) reviewed for blood glucose monitoring. Observations revealed 4 of 6 nurses (Licensed Practical Nurses (LPN) #1, #2, #3, and #4) failed to disinfect the blood glucose meters after use on each Resident observed during blood glucose monitoring/medication administration. The facility failed to monitor the lint dryers for 2 of 2 (Dryer #1 and #2) dryers and failed to perform proper hand hygiene for 2 of 14 staff members (Certified Nursing Assistant (CNA) #1 and #8). [...]

Inspectors wroteBased on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 1 of 13 staff members (Certified Nursing Assistant (CNA) #1) failed to knock or request permission to enter residents' rooms during dining.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to provide 3 of 3 sampled residents (Resident #29, #44, and #202) with the Advanced Beneficiary Notice (ABN), Center for Medicare and Medicaid Services (CMS)-10055 when therapy services were discontinued, and 8 of 8 sampled residents (Resident #249, #250, #251, #252, #253, #254, #255, and #256) were not refunded their personal funds within 30 days of discharge.

Inspectors wroteBased on policy review, medical record review, facility interviews with staff, and interview, the facility failed to report alleged violation involving injuries of unknown source to the State Agency, Police, Adult Protective Services (APS) and Long-Term Care Ombudsman immediately within the 2-hour time frame for 1 of 3 (Resident #199) sampled residents reviewed for abuse and resident rights. The failure of the facility to report an allegation of potential abuse related to an injury of unknown origin resulted in actual harm when Resident #199 sustained a fractured femur.

Inspectors wroteBased on policy review, medical record review, facility investigation and interview, the facility failed to thoroughly investigate an alleged incident of abuse that included an injury of unknown source for 1 of 3 sampled residents (Resident #199) reviewed for abuse. The facility's failure to thoroughly investigate the alleged violation, prevent further potential abuse from occurring, and take appropriate corrective actions resulted in actual harm when Resident #199 sustained a fracture of unknown source.

Inspectors wroteBased on medical record review, and interview, the facility failed to implement Comprehensive Care Plans for 5 of 13 sample resident (Resident #27, #30, #38, #42, and #44) reviewed for care planning.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to include the resident and/or family member in the Interdisciplinary Team (IDT) Care Plan meeting for 1 of 9 sampled residents (Resident#19) reviewed for Care Plan Meetings.

Inspectors wroteBased on policy review, medical record review and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided related to bathing for 1 of 3 sampled residents (Resident #44) reviewed for ADL care.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to accurately assess pressure ulcers for 1 of 3 sampled residents (Resident #19) reviewed for pressure ulcers.

Inspectors wroteBased on policy review, medical record review and interview, the facility failed to complete neurological (neuro) checks for 1 of 3 (Resident #44) sampled residents reviewed for accidents.

Inspectors wroteBased 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 1 of 3 (Resident #30) sampled residents reviewed for indwelling catheters.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 6 Licensed Practical Nurse (LPN #4) nurses observed during medication administration left 1 of 3 (Medication Cart A) medication carts unlocked and unattended.