You are on page 1of 39
PRINTED: 09/26/2018 FORM APPROVED. Division of Health Care Faciilies SIATEWENT OF DEFIOENCIES | (K+) PROWDERSUPPUFRGIA —] pay MULTPLE CONSTRUCTION (oa) OATE SURVEY AND PLAN OF CORRECTION toenncarionnunger | 030000" oMPLsTE c ‘TWPL536570 8 og 09/24/2018 NAME OF PROMIDER OR SUPPLIER SSTREETADORESS, CITY, TATE, IP CODE 4965 BRUNSWICK RD eae esars ARLINGTON, TN 38002 or ‘SUMARY STATEMENT OF DERCENCIES io FROUBERS PLAN OF CORRECTION © eek (eacitbePcichcy MUST Be PRECEOED BY FULL PREF (GACH CORRECTIVE ACTION SHOULD BE_—_cobvere TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ne CHOSEREFERENGED OTHE APPROPRIATE DATE DEFICIENCY) 001 1200-811 Initial Comments E001 This Rule is not met as evidenced by. ‘Complaint investigations were conducted for complaints #TN 00045695 and TN 00045350.0n 9/19/18 through 9/24/18, | ‘A Police Detective from Bartett TN was also conducting a compiaint investigation at the care home at the same time. Based on record review, observations and interviews, the Administrator failed to assume responsibilty for the operations of the care home and ensure residents received the care and services they needed, and that qualified personnel in the home administered medications and Percutaneous Endoscopic Gastrostomy (PEG) feedings. ‘These findings are detrimental to the health, safety and well-being of the residents in the care home, | A telephone exit conference was completed on 9/24/48 at 1:02 PM with the owner of the facil, 401, 1200-08-11-.04 (1) Administration E401 (1) The licensee shall be atleast eighteen (18) years of age, of reputable and responsible Character, able to comply with these rules, and must maintain financial resources and income sufficient to provide for the needs of the residents, including their room, board and personal services. This Rule is not met as evidenced by. Based on record review, observations and ‘wion of Hani Caro Factibee LASORATORY DIRECTOR'S OR PROVIDERISUPP REPRESENTATIVES SIGNATURE nme STATE FORT = Tevet Teen TTT PRINTED: 09/25/2018 FORM APPROVED Division of Health Gare Faciltios STATEMENT OF DEFICIENCIES | xi) PROWIOERISUPPLIERIGUA —] bey MUCTPLE CONSTRUCTION [poy DAE SURVEY [AND PLAN OF CORRECTION wewnincanonnuw@eR™ — |S sumone couPLEreD c -TNPLS36670 WN osi2ai2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, 21P CODE 4965 BRUNSWICK RO SS ARLINGTON, TN 38002 a) SUWUARY STATENENT OF DEFCIENOES D PROWBERS FLAN OF CORRECTION a, FREAK ——_(CAGH DeRICIENGY MUST BE PRECEDED ey FULL tere GEACHCORMECTIVEACON SHOULD SE colicre Tee _EGULATORY OR LSC DENTIFMING INFORMATION) “ae CAOSEREFERENGED foTME APPROPRIATE “OnE DeFICENCY) 401 Continued From page 1 E401 interview, the Administrator failed to exhibit responsible characteristics and ensure the facility staff abided by the rules for a home for the aged and provided appropriate needs for the resident of the care homes for 1 of 1 (Administrator #1) | ‘Administrators of the home for the aged. ‘The findings included: | 1, The Administrator failed to ensure the person in charge during her absence (Employee #3) was responsible for the care of the residents by allowing @ unlicensed caregivers (Employee #1 and Employee #3) administer medications to the residents, Employee #1 did not have a personne! file at the | facility | Employee #1 was untruthful abouthow many | resigents were living at the care home. Employee #1 could not provide the surveyor with an up-to-date log of the residents in the care home, Employee #3 had asked Employee #1 to remove ‘a resident from the home without the knowledge Of the surveyor onsite and the Police Detective (PD) onsite. The employee attempted to remove the resident however was stopped by the PD. Review of Hospice care notes provided by the Hospice agency, the Administrator failed to maintain medical records for care of a discharged resident (Resident #10), Review of the Hospice notes revealed the resident was not provided the recommended care | (elevation of lower extremities) to a resident (Resident #10) who had sweling of the lower | extremities, The resident developed a draining stasis ulcer to the lower extremities that required json of Heath Gare Facies STATE FOR eo revert Heontnuston see 20138 PRINTED: 09/25/2018 FORM APPROVED, Division of Health Care Facilities STATEMENT OF DEFICIENCIES — | X:) PROVOERSUPPLIERI [AND PLAN OF CORRECTION rpenmimcarionnumaer” — |e eutpme Th] ay MOLTIPLE CONSTRUCTION ay DATE SURVEY c ‘TNPLS36570 —————— 09/24/2018 NAME OF PROVIDER OR SUPPLIER SSTREETADORESS, CTY, STATE, 1P CODE 4965 BRUNSWICK RD CARING ESTATES ARLINGTON, TN 38002 PROVIDERS PLAN OF CORRECTION 2 (GACHCORRECTIVEACTION SHOULD 8 | COMPLETE CROSS HEFERENCED TO THE APPROPRIATE DATE DEFICeNGY) a1 "SUMMARY STATENENT OF DEFICIENCIES Pred | (GACH DEFICIENCY MUST BE PRECEDED BY FULL PRE tae REGULATORY OR USC IDENTIFYING INFORMATION) ae 401 Continued From page 2 E401 dressing changes, the resident was transferred to the hospital for treatment, then to a LTC facility where she expired. Refer to tag 402, 415, 418 2. The Administrator failed to ensure the persons in charge in her absence provided all the required | records as requested by the state surveyor. | | ‘There were 2 current residents (Resident's #1 and #11) and one discharged resident (Resident #10) whose records were not avaitabe for review. Refer to tag 421 5. The Administrator failed to ensure health records were current and up-to-date for Employee #1, There was no health record available, Refer to tag 427. 6. The Administrator allowed a resident whose care was not within the care home's licensure Capacity to be admitted fo the home. Resident #11 was an above knee amputee residing in a hospital bed and required tube feedings per percutaneous Endoscopic Gastrostomy (PEG). The resident also required liquid Morphine Sulfate medication for chronie pain syndrome to be administered, There was no lensed person in| the care home to administer the Morphine to the resident. Refer to tag 601 and 612. 7. The Administrator failed to ensure a written admission agreement and patient's rights were obtained for Resident's #1 ana #11 aan of oath Cave Facies STATE FORM mn sevens Iconanton shat 9.98