Weakley Rehabilitation and Nursing Center

Inspectors wroteBased on medical record review, hospital records review, and interview, the facility failed to implement a physician's order for a Bilevel Positive Airway Pressure (BIPAP) (a compact, non-invasive ventilator that assists with breathing by delivering pressurized air through a mask) for 1 of 3 (Resident #1) residents reviewed for respiratory care.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to ensure residents maintained acceptable parameters of nutritional status and implement nutritional interventions for 1 of 4 (Resident #38) sampled residents reviewed for weight loss. This resulted in an actual Harm when the facility failed to implement interventions following a significant weight loss for Resident #38 resulting in another significant weight loss 29 days later.

Inspectors wroteBased on policy review, facility documentation review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when the dishwasher did not meet the sanitary temperature requirement of 180 degrees Fahrenheit (F), and when staff failed to accurately complete the dishwasher temperature logs for 48 of 51 residents receiving meal trays.

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 5 of 10 staff (Certified Nursing Assistant (CNA) D, E, F, Housekeeping Aide G and H) failed to donn (put on) and doff (remove) proper Personal Protective Equipment (PPE) and perform hand hygiene for 4 of 21 (Residents #11, #12, #19 and #28) residents in droplet precautions and when 1 of 4 staff (Licensed Practical Nurse (LPN) C) failed to sanitize reusable equipment during medication administration.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to ensure medication monitoring related to the use of an antipsychotic (a type of medication used to treat psychiatric conditions) medication for 1 of 5 (Resident #8) sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored when medications were found unsecured and unattended in 2 of 51 (Resident #4 and Resident #34) resident rooms and when 2 of 5 (Licensed Practical Nurse (LPN) B and C) staff left medications unsecure and unattended on 2 of 6 (North Hall Cart and South Hall Cart) medication storage carts.

Inspectors wroteBased on review of the State licensure regulations, job description review, policy review, medical record review, review of facility investigations, observation, and interview, the facility failed to ensure the environment was free from accident hazards when dangerously elevated hot water temperatures were measured for 8 of 69 (Resident Rooms #13, #17, #18, #86, #89, #90, #91, #93) rooms, and when the facility failed to provide a safe environment and adequate supervision to prevent falls and injury for 7 of 7 (Resident #2, #11, #21, #28, #46, #52, and #54) sampled residents reviewed for accidents. On 6/24/2024 and 6/28/2024, dangerous elevated hot water temperatures ranging from 123 degrees Fahrenheit (F) to 130 degrees Fahrenheit (F) were observed in 8 of 69 (Resident Rooms #13, #17, #18, #86, #89, #90, #91, #93). [...]

Inspectors wroteBased on policy review, facility investigation review, police report review, documentation review, medical record review, and interview, the facility failed to protect the resident's right to be free from abuse from another resident for 1 of 4 (Resident #42) sampled residents reviewed for abuse. The facility's failure to protect the resident's right to be free from abuse resulted in actual HARM, when on 1/17/2024, Resident #42 sustained two lacerations to the forehead when Resident #166 hit Resident #42 in the head with a hard plastic drinking cup.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 2 of 6 medication carts (Northeast Cart and [NAME] Cart) was left unlocked and unattended during medication administration.

Inspectors wroteBased on review of the job description review, review of the State Licensure Regulations, policy review, medical record review, observation, and interview, the facility Administration failed to provide oversight to monitor and prevent hot water temperatures in resident care areas, failed to ensure a safe environment and adequate supervision to prevent falls, failed to prevent resident to resident abuse, and failed to ensure a resident with behaviors received appropriate care and services for 10 of 63 residents (Resident #17, 36, 40, 41, 43, 44, 52, 55, 166, and 370) residents.

Inspectors wroteBased on facility policy, medical record review, observation, and interview, the facility failed to ensure residents were free of physical restraints for 1 of 1 (Resident #9) sampled residents reviewed for restraints.

Inspectors wroteBased on policy review, medical record review, facility investigation, named Sheriff's Department Incident Report, and interview, the facility failed to thoroughly investigate an alleged incident of Employee to Resident abuse for 1 of 4 sampled residents (Resident #216) reviewed for abuse.

Inspectors wroteBased on policy review, medical record review and interview, the facility failed to complete a baseline care plan within 48 hours for 2 of 10 (Resident #21 and 369) sampled residents reviewed for baseline care plans.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to provide services to meet the behavioral needs and implement effective behavior monitoring for 1 of 4 sampled (Resident #166) residents reviewed for behavioral health needs.

Inspectors wroteBased on policy review, review of the medical record, Controlled Substance Inventory Record review, and interview, the facility failed to ensure the proper reconciliation of controlled medications when 1 of 4 nurses (Licensed Practical Nurse (LPN C) failed to sign out controlled medications on the Controlled Substance Inventory Record and keep a running count of medications on hand.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to update and revise the Three-Day Disaster Menu to accurately reflect the 3 Day Emergency Food Supply.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to follow Enhanced Barrier Precautions to prevent the spread of infection when 1 of 1 Licensed Practical Nurse (LPN) D failed to wear the correct Personal Protective Equipment (PPE) and when LPN D contaminated the wound during wound care for 1 of 3 (Resident #28) sampled residents for wound care.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to ensure a discharge summary was written within 14 days for 2 of 3 (Resident #59 and #110) discharged sample residents.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to accurately assess residents for Respiratory Services and Weight Loss for 2 of 17 (Resident #7, and #55) sampled residents reviewed for accuracy of Minimum Data Set (MDS) assessments.

Inspectors wroteBased on policy review, medical record review and interview, the facility failed to develop a baseline care plan within 48 hours for 1 of 3 (Resident #58) closed record reviews.

Inspectors wroteBased on policy review, medical record review, and interview the facility failed to ensure residents' Care Plans were reviewed and revised in a timely manner for 5 of 17 (#7, #17, #38, #55 and #110) sampled residents.

Inspectors wroteBased on the facility's 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, provide catheter care, and record urinary output for the use of an indwelling urinary catheter (a plastic tube inserted into the bladder used to drain urine into a plastic bag) for 1 of 2 sampled residents (Resident #310) reviewed for the use of an indwelling urinary catheter.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to follow the facility's policy for monitoring weekly weights for 2 of 3 (Resident #38 and #55) sampled residents reviewed for nutritional status. Review of the facility's policy titled Weight Monitoring dated 10/2022, revealed .The facility will ensure that all residents maintain acceptable parameters of nutritional status .significant unintended changes .may indicate a nutritional problem .weight monitoring schedule .newly admitted residents-monitor weight weekly for 4 weeks .residents with weight loss-monitor weight weekly . Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses of Respiratory Failure, Cerebral Infarction, Metabolic Encephalopathy, Seizures, Dementia, Moderate Protein Calorie Malnutrition, COVID-19, and Sepsis. [...]

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to monitor oxygen tubing, nasal cannula, or oxygen humidifier maintenance for 1 of 1 resident (Resident #7) reviewed for respiratory services.

Inspectors wroteBased on the facility's policy review, medical record review, and interview, the facility failed to ensure residents were free from significant medication errors for 1 of 5 sampled residents (Resident #39) reviewed for unnecessary medication when Resident #39's vital signs were not monitored and documented prior to administration of Digoxin (a medication for heart failure) and Metoprolol (a medication for high blood pressure).

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 6 staff members (Licensed Practical Nurse (LPN) #3) left the medication cart unlocked, unattended, and out of sight in 1 of 6 (East/North Hall medication cart) medication storage areas.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 3 of 12 staff members Certified Nurse Aide (CNA #1), (CNA #2), and Licensed Practical Nurse (LPN #1) failed to perform proper hand hygiene during meal service.