Brigadier General Wendell H Gilbert TN State Veter

In the surveyor’s words

From the most serious findings on record at Brigadier General Wendell H Gilbert TN State Veter, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 8, 2022

  Based on facility investigation, policy review, medical record review, observation, and interview, the facility failed to follow interventions to prevent falls and injury for 2 of 13 sampled residents (Resident #22 and #25) reviewed for accidents. The facility's failure to follow fall interventions resulted in Actual Harm when Resident #22 sustained a fall which resulted in a closed fracture (broken bone) of left distal femur (large upper bone of the leg), subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), cervical (neck) spine fracture, closed extensive facial fractures, rib fractures, closed fracture of distal end of the left humerus (long bone in the upper arm) and a chest wall hematoma (blood that has collected under the skin) and when… […]

• No harm, potential for more than minimal, widespreadF880Apr 8, 2022

  Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, review of Employee Screening Logs, Employee Schedules, assignment sheets, and interview, the facility failed to follow CDC infection control guidelines to ensure practices to prevent the potential spread of COVID-19 when 9 of 113 employees (Registered Nurse (RN) #1, #2, and #3, Licensed Practical Nurse (LPN) #1 and #2, and Certified Nursing Assistant (CNA) #1, #2, #3, and #4) failed to complete screenings for prevention and detection of COVID-19 prior to working 4 of 4 days (3/25/2022, 3/26/2022, 3/27/2022, and 3/28/2022) reviewed. This had the potential to affect the 83 residents residing in the facility. […]

• No harm, potential for more than minimal, isolatedF656Jun 4, 2026

  Based on facility policy review, medical record review, observation, and interview, the facility failed to develop and implement an individualized Comprehensive Care Plans for 3 of 21 (Resident #33, #101, and #104) residents sampled. The findings include: 1. Review of the facility policy titled, Clinical Comprehensive Care Plans Policy, dated 3/1/2016, revealed .[Named Company] will utilize information gathered from the Minimum Data Set [MDS], family and Resident interviews/assessments to develop, review, and revise the Resident's Comprehensive Plan of Care. […]

• No harm, potential for more than minimal, isolatedF695Jun 4, 2026

  Based on facility policy review, medical record review, observation, and interview, the facility failed to follow physician's orders for oxygen administration for 1 of 1 (Resident #84) residents reviewed for respiratory care. The findings include: Review of the facility policy titled, Oxygen Policy, dated 2/20/2013, revealed .Oxygen will only be administered with a Physician's order. Review of the facility policy titled, .MEDICATION ADMINISTRATION. dated 1/2018, revealed .Medications are administered as prescribed in accordance with good nursing principles and practices.Medications are administered in accordance with written orders of the prescriber. […]

• No harm, potential for more than minimal, isolatedF600Nov 21, 2025

  Based on facility policy review, medical record review, facility camera footage recording review, police report review, and interview, the facility failed to ensure the residents' right to be free from sexual abuse for 2 of 3 (Resident #1 and Resident #2) sampled residents reviewed for abuse. The findings include: 1. Review of the facility policy titled, Abuse & [and] Neglect of Resident and Misappropriation of Residents' Property, dated 2/20/2013, revealed .In keeping with our facility philosophy to promote the total well-being of our residents through the provision of the highest quality of care with the goal of maintaining or enhancing each resident's functional level and quality of life, [Named facility] takes a firm stand on the issues of mistreatment, neglect, or abuse of residents… […]