Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Census: 85
Deficiencies: 9
Jul 17, 2024
Visit Reason
Routine inspection of Life Care Center of Red Bank to assess compliance with regulatory requirements including resident rights, notification of condition changes, assessment accuracy, PASARR coordination, feeding tube care, respiratory equipment storage, food safety, garbage disposal, and infection prevention.
Findings
The facility was found deficient in multiple areas including failure to protect resident privacy, failure to notify representatives of condition changes timely, inaccurate Minimum Data Set (MDS) assessments, failure to resubmit PASARR after new mental health diagnoses, improper feeding tube bag changes, improper storage of respiratory equipment, unsanitary food storage and preparation areas, unclean garbage storage area, and failure to implement Enhanced Barrier Precautions (EBP) for residents with invasive devices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure medical information was not visible for 1 resident (Resident #52). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify resident representatives of a change in condition for 2 residents (Residents #14 and #46). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately complete Minimum Data Set (MDS) assessments for 4 residents (Residents #1, #84, #45, and #52). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to resubmit a Pre-admission Screening and Resident Review (PASARR) timely after new mental health diagnoses for 2 residents (Residents #11 and #39). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to change a tube feeding bag and tubing every 24 hours for 1 resident (Resident #587). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store nebulizer and CPAP masks appropriately for 3 residents (Residents #587, #588, and #589). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food items were stored properly and dishes and food preparation equipment were clean and sanitary, potentially affecting 84 of 85 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure garbage and refuse storage area was kept in a sanitary condition. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement Enhanced Barrier Precautions (EBP) for 8 residents with invasive devices. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents observed: 85
Residents reviewed for PASARR: 10
Residents reviewed for MDS accuracy: 42
Residents reviewed for respiratory equipment: 21
Residents reviewed for invasive devices: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Responsible for Resident #34's care; unaware of Enhanced Barrier Precautions |
| LPN D | Licensed Practical Nurse | Confirmed tube feeding bag was used for 3 days for Resident #587 |
| LPN MDS Coordinator C | Licensed Practical Nurse MDS Coordinator | Confirmed inaccurate MDS assessments and lack of family notification for Resident #46 |
| DON | Director of Nursing | Confirmed multiple deficiencies including lack of signage and PPE for EBP, lack of family notification, and inaccurate MDS assessments |
| ADON | Assistant Director of Nursing | Confirmed improper storage of respiratory equipment for Residents #587, #588, and #589 |
| CDM | Certified Dietary Manager | Confirmed unsanitary food storage and preparation conditions |
| NP H | Nurse Practitioner | Confirmed no respiratory illnesses despite exposed respiratory equipment |
| Regional Director of Clinical Services | Confirmed facility was not observing Enhanced Barrier Precautions unless ordered by physician | |
| Executive Director | Confirmed staff did not follow food storage policy in nourishment rooms |
Inspection Report
Complaint Investigation
Deficiencies: 4
Feb 29, 2024
Visit Reason
The inspection was conducted due to complaints and investigations related to failure to implement comprehensive care plans and prevent falls resulting in injuries for Resident #3.
Findings
The facility failed to follow the comprehensive care plan for Resident #3, resulting in multiple falls and injuries including fractures. The facility also failed to provide adequate supervision and proper transfer techniques, and did not maintain accurate medical records documenting refusals of care and resistance to transfers. Corrective actions and education were implemented following a root cause analysis.
Complaint Details
The complaint investigation focused on Resident #3 who sustained multiple injuries due to failure to follow care plans and improper transfer methods. The facility was cited for past non-compliance and corrective actions were verified.
Severity Breakdown
Level of Harm - Actual harm: 3
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to implement a complete care plan for Resident #3 resulting in actual harm from falls and injuries. | Level of Harm - Actual harm |
| Failure to prevent falls with major injury for Resident #3 due to inadequate supervision and improper transfer techniques. | Level of Harm - Actual harm |
| Failure to provide effective administration oversight and follow corporate notification protocol for falls with major injury. | Level of Harm - Actual harm |
| Failure to maintain accurate medical records documenting refusals of care and resistance to transfers for Resident #3. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for care plans for accidents: 5
Residents reviewed for accidents: 5
Residents reviewed for falls and injuries: 5
Residents reviewed for medical records: 15
Residents affected: 1
Residents in facility: 86
Staff education completion date: 2023
Audit duration: 12
Date of compliance: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #6 | Certified Nursing Assistant | Failed to follow care plan for transfers on 9/26/2022 and 5/1/2023 resulting in resident injuries. |
| Director of Nursing | Director of Nursing (DON) | Confirmed failures in following care plans and notification protocols. |
| Restorative Certified Nursing Assistant | R-CNA | Reported Resident #3's resistance to mechanical lift usage and refusal to transfer. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Reported Resident #3's resistance to care and failure to document refusals. |
| Registered Nurse #1 | Registered Nurse (RN) | Reported Resident #3's resistance to transfers and failure to document refusals. |
| Regional Director of Clinical Services | RDCS | Reported failure of former DON to notify corporate team of Never Event fall. |
| CNA #7 | Certified Nursing Assistant | Failed to have two staff present during sit to stand lift transfer on 12/27/2022. |
| CNA #2 | Certified Nursing Assistant | Reported Resident #3's resistance to care and refusal of transfers. |
| CNA #3 | Certified Nursing Assistant | Reported Resident #3's resistance to transfers and notification to nurse. |
| Administrator | Facility Administrator | Confirmed completion of corrective action audits and QAPI meetings. |
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 23, 2023
Visit Reason
The document is an annual inspection report for Life Care Center of Red Bank conducted to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 3
Feb 1, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to notify the physician or nurse practitioner of critical laboratory values, failure to timely report the results of an abuse investigation, and failure to accurately reconcile admission medication orders for residents.
Findings
The facility failed to notify the physician or nurse practitioner of critical lab values for one resident, failed to timely report the results of an abuse investigation to the State Survey Agency for another resident, and failed to accurately reconcile admission medication orders for one resident, resulting in discrepancies in medication dosing.
Complaint Details
The complaint investigation revealed that the facility did not notify the NP of critical lab values for Resident #6 on 10/3/2022, did not report the results of an abuse investigation for Resident #2 within the required 5 working days, and failed to reconcile medication orders accurately for Resident #6 upon admission.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to notify the Physician or Nurse Practitioner of a critical laboratory value for Resident #6. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report the results of an abuse investigation to the State Survey Agency for Resident #2. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately reconcile admission medication orders for Resident #6, resulting in medication dosing discrepancies. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Critical lab values: 1
Residents reviewed for physician notification: 5
Residents reviewed for abuse: 4
Residents reviewed for medication reconciliation: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Unit Coordinator | Confirmed receipt of critical lab values and involvement in medication reconciliation for Resident #6 |
| Nurse Practitioner (NP) | Ordered IV fluids and repeat labs for Resident #6; confirmed expectation to be notified of critical labs | |
| Director of Nursing (DON) | Director of Nursing | Confirmed expectation for nurses to notify provider of critical lab values |
| Medical Director (MD) | Medical Director | Confirmed expectation for notification of critical lab values and accurate medication reconciliation |
| Licensed Practical Nurse (LPN) #1 | Admissions Nurse | Entered medication orders into EHR and involved in medication reconciliation for Resident #6 |
| Administrator | Administrator | Confirmed failure to timely report abuse investigation results |
| Nephrologist | Provided opinion on Resident #6's outcome related to delayed notification of critical labs | |
| PCP NP | Primary Care Physician Nurse Practitioner | Sent admission orders and confirmed home medication dosages for Resident #6 |
Inspection Report
Complaint Investigation
Deficiencies: 6
Oct 20, 2021
Visit Reason
The inspection was conducted to investigate complaints related to medication administration, resident abuse, medication safety, psychotropic medication use, and food safety at the Life Care Center of Red Bank.
Findings
The facility failed to ensure proper medication administration practices, including allowing residents to self-administer nebulizer treatments without assessment and leaving medications unattended. The facility also failed to protect a resident from abuse by another resident, did not timely report the abuse allegation to the State Survey Agency, and did not thoroughly investigate the abuse allegation. Additionally, the facility failed to implement gradual dose reductions for psychotropic medications and failed to label and discard moldy food items in the kitchen.
Complaint Details
The complaint investigation revealed failures in medication administration practices, resident abuse protection, abuse reporting, abuse investigation, psychotropic medication management, and food safety.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate; nursing staff did not stay with residents during nebulizer treatments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect a resident from abuse by another resident and did not thoroughly investigate the allegation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report an allegation of abuse to the State Survey Agency. | Level of Harm - Minimal harm or potential for actual harm |
| Medications were left unattended at the bedside, failing to ensure safe medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement gradual dose reductions for psychotropic medication and failed to timely renew PRN anti-anxiety medication orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to date and label bread products and failed to discard molded bread available for resident use. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for medication administration: 6
Residents reviewed for abuse: 15
Residents affected by food safety issue: 80
Residents in facility: 85
Days PRN order not renewed timely: 21
Bread products undated: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Administered nebulizer treatments and left residents unattended. |
| RN #1 | Registered Nurse | Administered nebulizer treatments and left residents unattended. |
| Director of Nursing | Director of Nursing (DON) | Confirmed policy violations, lack of abuse investigation, and failure to report abuse. |
| LPN #1 | Licensed Practical Nurse | Reported abuse allegation to DON. |
| Unit Manager #1 | Unit Manager | Confirmed failure to attempt gradual dose reduction and timely renew PRN medication order. |
| Dietary Director | Dietary Director | Confirmed undated and molded bread products were available for resident use. |
| Registered Dietician | Registered Dietician (RD) | Confirmed facility expectations for labeling and discarding bread products. |
Inspection Report
Routine
Deficiencies: 4
Jul 31, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including pre-admission screening and resident review program referrals, pain management, fall prevention, and overall quality of services provided by the nursing facility.
Findings
The facility failed to make required referrals for PASARR Level II screening for residents with newly diagnosed serious mental disorders, failed to follow professional standards for pain management resulting in actual harm to a resident, and failed to ensure adequate supervision to prevent a resident fall. These deficiencies resulted in minimal to actual harm to a few residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Level of Harm - Actual harm: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to make a referral to the state-designated authority for a Level II PASARR after newly identified serious mental disorders were diagnosed for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow professional standards of practice per the comprehensive care plan for pain management for 1 resident, resulting in actual harm. | Level of Harm - Actual harm |
| Failed to ensure adequate supervision for 1 resident, resulting in a fall. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide effective pain management for 1 resident, resulting in severe, unrelieved pain and actual harm. | Level of Harm - Actual harm |
Report Facts
Residents reviewed for PASARR: 21
Residents reviewed for pain management: 21
Residents reviewed for falls: 21
Residents affected: 2
Residents affected: 1
Residents affected: 1
Pain rating: 9
BIMS score: 3
BIMS score: 13
PRN oxycodone-acetaminophen doses administered: 3
Delay in pain medication administration: 6.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Charge Nurse #1 | Licensed Practical Nurse | Named in pain management deficiency for failing to administer PRN pain medication timely to Resident #87 |
| Director of Nursing | Director of Nursing | Confirmed failures in PASARR referral, pain management, and supervision leading to deficiencies |
| Certified Nursing Assistant CNA #1 | Certified Nursing Assistant | Left Resident #26 unsupervised in shower room leading to fall |
| Charge Nurse #1 | Charge Nurse | Confirmed CNA #1 left Resident #26 unsupervised and failed to administer pain medication timely to Resident #87 |
| Certified Nursing Assistant CNA #2 | Certified Nursing Assistant | Reported Resident #87's pain and request for medication to Charge Nurse #1 |
| Unit Supervisor #1 | Unit Supervisor | Confirmed failure to administer PRN pain medication to Resident #87 |
Loading inspection reports...
