Inspection Reports for The Waters of Gainesboro
1340 North Grundy Quarles Highway, Gainesboro, TN, 38562
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than Tennessee average
Tennessee average: 4.4 deficiencies/year
Deficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 2
Date: Nov 29, 2023
Visit Reason
The inspection was conducted to assess compliance with physician orders and respiratory care standards for residents, including review of medical records, facility policies, observations, and interviews.
Findings
The facility failed to follow physician orders for oxygen administration for Resident #3, administering oxygen at 4 lpm instead of the ordered 2 lpm. Additionally, the facility failed to ensure proper respiratory care for Residents #3 and #4, including improper storage and lack of dating on nebulizer masks and oxygen equipment.
Deficiencies (2)
Failed to follow Medical Doctor's orders for oxygen administration for Resident #3, administering oxygen at 4 lpm instead of the ordered 2 lpm.
Failed to provide safe and appropriate respiratory care for Residents #3 and #4, including undated and improperly stored nebulizer masks and oxygen equipment.
Report Facts
Residents reviewed: 17
Residents reviewed: 2
Oxygen flow rate ordered: 2
Oxygen flow rate observed: 4
BIMS score: 15
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Nurse Consultant #2 | Verified oxygen concentrator settings and confirmed non-compliance with physician orders for Resident #3 | |
| Director of Nursing (DON) | Interviewed regarding improper storage and lack of dating on nebulizer masks and oxygen equipment for Residents #3 and #4 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report allegations of abuse involving Resident #3.
Complaint Details
The complaint investigation found that the facility did not report suspected abuse within the required 2-hour window. The allegation involved CNA #3 allegedly hitting Resident #3, which was reported by CNA #2 to the Director of Nursing on 5/15/2022 but was only reported to the state agency on 5/16/2022. Resident #3 had a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. Interviews with involved staff confirmed the delay in reporting.
Findings
The facility failed to report allegations of abuse within the required 2-hour timeframe for Resident #3. Interviews and reviews revealed that the abuse allegation was reported to the Director of Nursing on 5/15/2022 but was not submitted to the state agency until 5/16/2022, a day late. Resident #3 had severely impaired cognition and denied injury or pain.
Deficiencies (1)
Failure to timely report allegations of abuse within 2 hours for Resident #3.
Report Facts
Brief Interview for Mental Status (BIMS) score: 3
Number of residents sampled for abuse review: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Reported the abuse allegation to the Director of Nursing |
| CNA #3 | Certified Nursing Assistant | Alleged to have hit Resident #3; sent home immediately after allegation |
| Director of Nursing | Director of Nursing | Received abuse allegation and delayed reporting to state agency |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 6, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident dignity, professional standards of care, supervision to prevent accidents, and food safety.
Findings
The facility was found deficient in multiple areas including failure to ensure dignity for a resident with a urinary catheter, failure to obtain ordered lab tests for a diabetic resident, failure to provide adequate supervision to prevent elopement resulting in immediate jeopardy, and failure to maintain sanitary food service conditions including improper food storage and employee hygiene.
Deficiencies (4)
Failure to ensure dignity for 1 resident (#54) by not covering urinary catheter drainage bag as required by facility policy.
Failure to meet professional standards by not obtaining an ordered HbA1c lab for 1 resident (#11).
Failure to provide adequate supervision to prevent elopement for 1 resident (#68), resulting in immediate jeopardy to resident health or safety.
Failure to ensure food was served under sanitary conditions and failure to store foods safely, including a male dietary employee not wearing a beard guard and expired foods found in nourishment rooms.
Report Facts
Residents reviewed with urinary catheters: 7
Residents reviewed for lab order compliance: 28
Residents reviewed for elopement risk: 5
Trays plated without beard guard: 22
Expired orange juice cans: 6
Expired cantaloupe container: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding catheter bag placement and visibility |
| Registered Nurse #1 | Registered Nurse | Confirmed catheter bag was not covered with dignity bag |
| Director of Nursing | Director of Nursing | Confirmed catheter bag policy and elopement incident details |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Witnessed elopement incident on 7/27/19 |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Interviewed about elopement incident and nourishment room food checks |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Observed resident outside during elopement incident |
| Assistant Dietary Manager | Assistant Dietary Manager | Confirmed male dietary employee did not wear beard guard and discussed expired foods |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 5, 2018
Visit Reason
The inspection was conducted to investigate complaints related to failure to revise care plans for residents, failure to administer tube feeding as ordered, and failure to perform timely Abnormal Involuntary Movement Scale (AIMS) assessments.
Complaint Details
The visit was complaint-related, focusing on failure to update care plans, improper administration of tube feeding, and lack of timely AIMS assessments. Substantiation status is not explicitly stated.
Findings
The facility failed to update care plans for two residents, failed to administer tube feeding at the ordered rate for one resident, and failed to perform timely AIMS assessments for one resident receiving antipsychotic medications. These deficiencies were identified through policy review, medical record review, observations, and interviews.
Deficiencies (3)
Failed to revise care plans for 2 residents (#26 and #44) of 31 residents reviewed.
Failed to administer the rate of a tube feeding as ordered and failed to administer the tube feeding as ordered for 1 resident (#26) of 5 residents receiving tube feeding.
Failed to provide monitoring related to performing Abnormal Involuntary Movement Scale (AIMS) assessments in a timely manner for 1 resident (#4) of 27 residents receiving Anti-Psychotic medications.
Report Facts
Residents reviewed: 31
Residents receiving tube feeding: 5
Residents receiving Anti-Psychotic medications: 27
Tube feeding rate ordered: 40
Tube feeding rate observed: 50
Date of last AIMS assessment: Oct 24, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Interviewed regarding failure to update resident care plans |
| Director of Nursing | Director of Nursing | Interviewed regarding physician orders and care plan updates |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed regarding responsibility for updating care plans |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding tube feeding administration for Resident #26 |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Dec 6, 2017
Visit Reason
The inspection was conducted as part of a regulatory annual survey to assess compliance with healthcare facility standards and regulations.
Findings
The facility was found deficient in multiple areas including failure to provide dignified feeding assistance, failure to administer medications as prescribed, inadequate prevention of accidents resulting in harm, insufficient nursing staff leading to untimely medication administration, failure to monitor behaviors for residents on psychotropic medications, and failure to serve food at safe and appetizing temperatures.
Deficiencies (6)
Failed to provide feeding assistance in a dignified manner for 1 resident (#66) during dining observation.
Failed to follow physician orders to administer medications to 1 resident (#439) of 14 residents reviewed.
Failed to prevent an accident resulting in an arm fracture for 1 resident (#66) and failed to prevent elopement for 1 resident (#77).
Failed to provide sufficient nursing staff as evidenced by untimely medication administration on 3 of 7 days for 1 resident (#39).
Failed to monitor behaviors for 2 residents (#18, #42) of 6 residents reviewed for unnecessary psychotropic medications.
Failed to serve palatable food at a safe and appetizing temperature; food was often cold as reported by residents.
Report Facts
Residents observed during dining observation: 13
Residents reviewed for medication administration: 14
Residents reviewed for accident prevention: 14
Residents reviewed for nursing staff sufficiency: 14
Residents reviewed for psychotropic medication monitoring: 6
Medication administration delays: 3
Temperature of baked fish: 106
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in feeding assistance deficiency for Resident #66 |
| Director of Nursing | Director of Nursing (DON) | Confirmed multiple deficiencies including feeding assistance, medication administration, transfer training, and staffing |
| LPN #6 | Licensed Practical Nurse | Involved in accident investigation and care for Resident #66 |
| CNA #4 | Certified Nurse Aide | Reported bruise discovery and transfer methods for Resident #66 |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding accident prevention and door malfunction |
| Maintenance Director | Maintenance Director | Addressed malfunctioning exit door related to elopement risk |
| LPN #1 | Licensed Practical Nurse | Reported staffing shortages affecting medication administration |
| LPN #2 | Licensed Practical Nurse | Reported staffing shortages affecting medication administration |
| LPN #3 | Licensed Practical Nurse | Confirmed medication delays due to staffing |
| LPN #4 | Licensed Practical Nurse | Interviewed about behavior monitoring for psychotropic medications |
| Registered Dietitian | Registered Dietitian | Confirmed food temperature deficiency |
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