Inspection Reports for Nashville Center for Rehabilitation Center and Healing
TN
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
111% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 12
Mar 16, 2023
Visit Reason
The inspection was conducted as part of the annual survey of the nursing home to assess compliance with regulatory requirements including resident care, facility operations, and safety.
Findings
The facility was found deficient in multiple areas including failure to perform significant change MDS assessments, incomplete baseline care plans, lack of quarterly care plan conferences, inadequate discharge planning, unlabeled enteral feeding tubes, uncapped intravenous tubing, unsanitary kitchen equipment, lack of state approval for in-house dialysis unit, missing vaccination declination forms, inoperable call lights, and inadequate dining space.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to determine and perform a significant change Minimum Data Set (MDS) assessment for 1 of 40 sampled residents (Resident #16). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to create and provide a baseline care plan within 48 hours of admission for 5 of 40 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have quarterly care plan conference meetings with the resident or resident's representative for 11 of 40 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement an effective discharge planning process for 1 of 40 sampled residents (Resident #32). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure enteral feeding tube was labeled and dated for 1 of 5 sampled residents (Resident #77). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to apply hubs to the end of an Internal Jugular Vein catheter external limbs and failed to apply a hub and date IV tubing for 1 of 17 residents (Resident #216). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain clean and sanitary equipment for 1 of 3 ice machines and 2 of 2 stove drip pans; failed to properly store refrigerated foods in 1 of 2 walk-in coolers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain State approval to open a Long Term Care Hemodialysis Unit. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have declination forms for Influenza and Pneumococcal immunizations for 1 of 5 sampled residents (Resident #8). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have declination form for COVID-19 vaccination for 1 of 5 sampled residents (Resident #8). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have 1 of 40 operable call lights in resident bathrooms and bathing areas. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate dining space for 3 of 3 rooms in the facility. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 40
Residents affected: 1
Residents affected: 5
Residents affected: 11
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 40
Residents affected: 3
Residents receiving in-house dialysis: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Confirmed significant change MDS assessment requirements and care plan review process | |
| Wound Care Nurse | Confirmed resident decline and baseline care plan issues | |
| Social Service Director | Confirmed care plan conference practices and discharge planning deficiencies | |
| Unit Manager | Confirmed enteral tube labeling and IV tubing issues, call light malfunction | |
| Director of Nursing | Confirmed enteral tube labeling, IV tubing and catheter hub expectations | |
| Licensed Practical Nurse #4 | Confirmed uncapped IJ catheter limbs and undated IV tubing | |
| Dietary Aide #2 | Confirmed unsanitary drip pans, improper food storage, and ice machine misuse | |
| Administrator | Confirmed lack of state approval for dialysis unit and kitchen drip pan cleanliness | |
| Infection Preventionist | Confirmed missing vaccination declination forms and consent requirements | |
| Staffing Educator | Confirmed lack of communal dining area on Rehabilitation unit | |
| Activities Director | Confirmed multipurpose use of dining/activity room and limited communal dining |
Inspection Report
Routine
Deficiencies: 3
Apr 24, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to care planning, provision of meal assistance, and maintenance of accurate medical records in the nursing facility.
Findings
The facility failed to revise and update a care plan for one resident, failed to follow physician orders for total assistance with meals for one resident, and failed to maintain accurate and consistent medical records regarding resuscitation orders for another resident.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to revise and update a care plan for 1 resident (#46) of 52 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow physician orders to provide total assistance with meals for 1 resident (#46) of 52 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an accurate and complete record for 1 resident (#18) related to Physician Orders and POLST form not matching. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 52
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding meal assistance for Resident #46 |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding meal assistance for Resident #46 |
| Registered Nurse #1 | Registered Nurse | Interviewed confirming Resident #46 required total assistance with meals |
| Director of Nursing | Director of Nursing | Interviewed confirming care plan and physician orders issues for Residents #46 and #18 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding code status procedures for Resident #18 |
| 600 Hall Unit Manager | Unit Manager | Interviewed regarding code status procedures and discrepancies for Resident #18 |
Inspection Report
Routine
Deficiencies: 13
Apr 11, 2018
Visit Reason
Routine inspection of Nashville Center for Rehabilitation and Healing LL to assess compliance with healthcare regulations including resident rights, abuse reporting, assessments, care planning, medication administration, pain management, dietary services, and equipment safety.
Findings
The facility was found deficient in multiple areas including failure to obtain completed advance directives for residents, delayed abuse reporting, inaccurate resident assessments, incomplete baseline care plans, failure to provide ordered wound care and pain management, improper medication administration and documentation, failure to monitor psychotropic medication use, improper medication storage, failure to honor resident food preferences, and failure to maintain dietary equipment and sanitation standards.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 13
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to obtain completed advance directives for 8 of 31 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to report allegations of abuse within the required 2-hour timeframe for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately assess the Minimum Data Set (MDS) for 1 of 44 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to create baseline care plans addressing immediate needs for 5 of 44 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide wound care treatments as ordered for 1 of 44 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer enteral feeding per physician's order for 2 of 10 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe, appropriate pain management for 3 of 44 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct a drug regimen review for 1 of 8 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure PRN psychotropic medications had a 14-day limitation or prescriber documentation for continuation for 5 of 12 sampled residents and failed to conduct behavior monitoring for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly store medications in locked compartments and maintain refrigeration temperature logs in medication rooms; failed to lock treatment and medication carts when unattended. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to procure food from approved sources and failed to serve meals per menu and resident preferences for 6 of 86 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain accurate and complete medical records for 2 of 44 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain dietary slicer equipment in a safe operating condition. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for advance directives: 31
Residents reviewed for abuse reporting: 7
Residents reviewed for MDS accuracy: 44
Residents reviewed for baseline care plans: 44
Residents reviewed for wound care: 44
Residents reviewed for enteral feeding: 10
Residents reviewed for pain management: 44
Residents reviewed for drug regimen: 8
Residents reviewed for psychotropic medication: 12
Medication rooms reviewed: 4
Medication carts reviewed: 7
Treatment carts reviewed: 1
Residents reviewed for dietary services: 86
Residents reviewed for medical records: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed confirming multiple deficiencies including advance directives, abuse reporting, MDS accuracy, baseline care plans, enteral feeding, pain management, drug regimen review, psychotropic medication monitoring, medication storage, and medical record maintenance. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed confirming failures in wound care, pain management, and prevention of allergic reactions. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Administered enteral feeding at incorrect rate. |
| Licensed Practical Nurse #5 | Licensed Practical Nurse (Wound Nurse) | Interviewed regarding wound care for Resident #98. |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Interviewed regarding tube feeding administration for Resident #36. |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Unable to locate tube feeding documentation. |
| Licensed Practical Nurse #9 | Licensed Practical Nurse | Unable to locate tube feeding documentation. |
| Licensed Practical Nurse #10 | Licensed Practical Nurse | Left treatment cart unlocked; involved in wound care and dietary tray observations. |
| Licensed Practical Nurse #11 | Licensed Practical Nurse | Administered pain medications; involved in pain management observations. |
| Licensed Practical Nurse #12 | Licensed Practical Nurse | Administered delayed pain medication dose. |
| Registered Nurse #2 | Registered Nurse | Confirmed undated multi-dose vial and refrigeration temperature logging issues. |
| Registered Nurse #3 | Registered Nurse | Left medication cart unlocked and unattended. |
| Certified Dietary Manager | Certified Dietary Manager | Interviewed regarding dietary service deficiencies including food preferences, meal preparation, and equipment sanitation. |
| Registered Dietitian | Registered Dietitian | Interviewed regarding dietary service deficiencies and failure to assess food preferences. |
| Administrator | Administrator | Interviewed confirming abuse reporting deficiencies and dietary service issues. |
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