2 Reports
Inspection Report — Jul 13, 2023
Enforcement
Date: Jul 13, 2023
Visit Reason
Order assessing civil monetary penalties following a recertification and complaint survey at Trevecca Center for Rehabilitation and Healing, LLC that began on June 12, 2023 and whose investigation was completed on July 6, 2023.
Complaint Details
This order follows a recertification and complaint survey begun on June 12, 2023 and completed July 6, 2023 that revealed violations resulting in assessed penalties.
Findings
The Executive Director assessed three (3) Type B civil monetary penalties of $500 each, for a total assessment of $1,500, based on violations of Basic Services; the assessment is effective upon receipt and payable within five working days.
Citations (1)
Violations of Basic Services: surveyors found violations of licensure statutes and regulations that directly impacted the care of patients.
Report Facts
Civil monetary penalties assessed: 3
Total civil monetary penalty amount: 1500
Civil monetary penalty amount each: 500
Payment timeframe days: 5
Inspection Report — Aug 22, 2022
Enforcement
Date: Aug 22, 2022
Visit Reason
Order assessing a civil monetary penalty following an annual survey conducted on July 25, 2022, with the investigation completed on August 10, 2022.
Findings
The Executive Director assessed one (1) Type B civil monetary penalty of five hundred dollars ($500.00) against Trevecca Center for violations of Infection Control standards; the penalty is due within five working days of receipt of the Order.
Citations (1)
Infection Control standards: surveyors identified violations of infection control practices that were cited as the basis for the assessed Type B civil monetary penalty.
Report Facts
Civil monetary penalties assessed: 1
Total civil monetary penalty amount: 500
Payment due days: 5
4 CMS Surveys
Inspection Report — Jun 21, 2023
Enforcement
Date: Jun 21, 2023
Visit Reason
Statement of Deficiencies (CMS-2567) issued following a survey completed on 06/21/2023.
Findings
The facility was cited at F 0656 for failing to follow the comprehensive care plan for Resident #92; the care plan required total dependent transfers with a mechanical lift and two staff but staff were observed transferring the resident with a mechanical lift without another staff. Level of harm was recorded as minimal and residents affected were listed as few.
Citations (1)
F 0656: The facility failed to develop and implement a complete care plan meeting the resident's needs for Resident #92. Resident #92's plan required total dependent transfers with a mechanical lift and two staff, but CNA #9 was observed transferring the resident alone.
Report Facts
Sampled residents reviewed: 59
Sampled residents with cited deficiency: 1
Inspection Report — Jun 21, 2023
Enforcement
Date: Jun 21, 2023
Visit Reason
Statement of Deficiencies (CMS-2567) following a facility survey completed on 2023-06-21 for Trevecca Center for Rehabilitation and Healing LLC documenting multiple F-tag deficiencies identified during the survey.
Findings
The survey cited multiple deficiencies across F-tags (including F0585, F0625, F0657, F0677, F0685, F0692, F0757, F0800, F0806, F0812) with Level of Harm noted as minimal and residents affected described as 'Few.' Deficiencies included failures in grievance resolution, bed-hold notifications, care plan conferences, bathing/grooming, vision services, diet/food safety, medication monitoring, dietary preferences, and kitchen cleanliness.
Citations (10)
F0585: Facility failed to make prompt efforts to resolve grievances regarding missing personal belongings for Residents #36 and #155.
F0625: Facility failed to provide written bed-hold notice to the resident or the resident's representative at time of hospitalization for Residents #91, #118, #131, #137, and #224.
F0657: Facility failed to conduct care plan conference meetings with the resident or resident's representative for Residents #30, #88, #91, #103, #137, and #150 as required.
F0677: Facility failed to ensure scheduled showers/baths for Residents #11 and #27 and failed to provide nail care and grooming for Resident #27.
F0685: Facility failed to ensure timely eye care and necessary treatment/assistive devices to maintain vision for Resident #155 with reported visual decline.
F0692: Facility failed to follow physician orders for mechanically-altered diet and nectar-thickened liquids for Resident #219 when an unconfirmed supplement was provided.
F0757: Facility failed to adequately monitor for side effects or behaviors for Resident #27 after initiation of the antidepressant Remeron.
F0800: Facility failed to maintain hot food at or above 135°F during service; chicken noodle soup measured 130°F and other soups measured 129°F on the steam table.
F0806: Facility failed to accommodate dietary preferences for Residents #157, #170, #185, #186, and #194 and tray tickets did not reflect dislikes as reported by residents.
F0812: Dietary department failed to maintain and clean the range hood (hood observed covered with debris); CDM stated hood was cleaned only twice a year, last cleaned 2023-02-09.
Report Facts
Residents not provided bed-hold notice: 5
Care plan conferences missing: 6
Residents missed scheduled showers: 2
Resident with unclean fingernails: 1
Resident with unresolved vision needs: 1
Diet order not followed: 1
Antidepressant monitoring failures: 1
Chicken noodle soup temperature (°F): 130
Tomato soup temperature (°F): 129
Vegetable beef soup temperature (°F): 129
Range hood cleaning frequency (times per year): 2
Inspection Report — Apr 10, 2019
Enforcement
Date: Apr 10, 2019
Visit Reason
Statement of deficiencies (CMS-2567) from a survey completed on 2019-04-10 documenting cited deficiencies related to resident dignity during feeding and failure to investigate an incident.
Findings
Two deficiencies were cited: F 0550 for failure to treat Resident #212 with dignity when staff referred to residents as 'feeders' and delayed feeding, and F 0689 for failure to investigate an incident after a non-facility hypodermic syringe was found in Resident #13's room.
Citations (2)
F 0550: Failure to ensure resident dignity; staff referred to residents requiring feeding assistance as 'feeders' and Resident #212 reported being called a 'feeder' and made to wait to be fed.
F 0689: Failure to investigate accidents/incidents; the facility did not conduct an investigation after a non-facility hypodermic syringe was found in Resident #13's room.
Report Facts
Deficiencies cited: 2
Residents reviewed for feeding assistance: 45
Records reviewed: 69
BIMS score Resident #212: 15
BIMS score Resident #13: 14
Inspection Report — Mar 14, 2018
Enforcement
Date: Mar 14, 2018
Visit Reason
Statement of Deficiencies from a health survey completed on 03/14/2018, documenting deficiencies identified during the facility survey.
Findings
Two deficiencies were cited: F0725 for inadequate nursing staffing on the 5th floor resulting in residents waiting for care, and F0921 for an unclean tabletop fan in Resident #5's room.
Citations (2)
F 0725: Provide enough nursing staff every day to meet the needs of every resident. The facility failed to provide sufficient staffing on the 5th floor on 3/11/18, with four CNAs scheduled for 56 residents and residents waiting up to 45 minutes for care.
F 0921: Make sure that the nursing home area is safe, easy to use, clean and comfortable. A tabletop fan in Resident #5's room on 3/12/18 had a heavy accumulation of debris and was confirmed dirty by the Assistant Director of Nursing.
Report Facts
Deficiencies cited: 2
Residents on 5th floor: 56
CNAs scheduled: 4
Resident wait time minutes: 45
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