Every finding on record at Fort Sanders Tcu

Based on facility policy review, observations, and interview, the facility failed to properly store refrigerated and dry storage food items, which had the potential to affect 19 of 19 residents. The findings include: Review of the facility's policy titled, Food and Supply Storage, revised 1/2026, revealed .products contain an expiration date .best-by .or use-by .date .Cover, label and date unused portions and open packages .Use .labeling system or complete all sections on an orange label .products are good through the close of business on the date noted on the label .discard food past the use-by or expiration date . During an observation on 6/15/2026 at 10:17AM, with the Dietary Manager and Head Chef, revealed in the reach in cooler a plastic 6-inch container of sliced ham 1/2 full labeled with an orange sticker .Product Ham .Good Thru 06/11/26 . Further observation revealed an 8-quart plastic container with approximately 10 slices of sliced turkey breast labeled with an orange sticker .Product .Turkey Breast .Good Thru 06/11/26 . Continued observation of the dry storage area revealed 13-46 oz (ounce) containers of thickened consistency (product used for residents with difficulty swallowing) orange juice with an expiration date of 4/10/2026 and 2-46 oz containers of thickened cranberry juice with an expiration date of 4/9/2026. During an interview on 6/15/2026 at 10:45AM, the Dietary Manager and Head Chef confirmed the ham the sliced turkey breast was labeled with an orange sticker dated good thru 6/11/2026, 13-46 oz containers of thickened consistency orange juice and 2-46 oz of thickened consistency cranberry juice were expired and available for resident use.

Based on observation and interview, the facility failed to store food and equipment in a sanitary manner. The findings included: Observation on December 2, 2013, at 9:15 a.m., in the kitchen, revealed four pans of prepared Jello, cut in cubes, in refrigrator #1, labeled "...date prepared November 23, 2013...expiration date November 26, 2013..." Continued observation revealed an additional four pans of prepared Jello, in refrigrator #2, labeled "...date prepared November 23, 2013...expiration date November 26, 2013..." Review of facility policy, Food and Suppy Storage Procedures, last revised January, 2012, revealed "...cover, label and date unused portions and open packages...use the (named facility's) orange label...complete all sections on the label..." Inteview with the contractor's Dietary Manager (DM) on December 2, 2013, at 9:15 a.m., in the kitchen, revealed "...the Jello in refrigrator #2 was prepared today (December 2, 2013)...they did not change the label and reused the plastic wrap covering..." Continued interview with the DM confirmed the pans of Jello had expired on November 26, 2013, and were avalible for serving to the patients. Observation on December 3, 2013, at 10:10 a.m., in the clean diswashing area, revealed one fan hanging on the wall, in the on position, blowing directly on the clean area where the food trays are stored. Continued observation revealed dirty trays and food containers from the cafeteria, in the same area where the clean food trays were stored, and the fan blowing on the dirty and clean areas. Inteview with the DM on December 3, 2013, at 10:10 a.m., in the clean dishwashing area of the kitchen, confirmed the fan was blowing on the clean and dirty areas in the kitchen.

Based on medical record review and interview, the facility failed to follow physician's orders to conduct a diagnostic test timely for one resident (#218) of twenty-nine residents reviewed. The findings included: Resident #218 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician's Order dated November 12, 2012, at 9:42 a.m, revealed an order for [REDACTED]. record review revealed a Physician's Progress Note dated October 14, 2012, "...no echo results...apparently not done..." Review of a Physican's Order, for the same date (October 14, 2012), revealed "... make sure echo ordered on 10-12-12 done..." Continued medical record review revealed a notation in the progress notes, by the radiology department, dated November 15, 2012, at 10:00 a.m., indicating the echocardiogram had been completed. Interview with the Director of Nursing (DON) on November 15, 2012, at 1:35 p.m., in the conference room, revealed the night shift nurses are responsible for chart audits each night, to ensure the days treatments/orders are processed timely. Continued interview with the DON on November 15, 2012, at 2:20 p.m., in the nurse's station, revealed the echocardiogram status had not been confirmed during the chart audit on November 12 and 13, 2012. Interview with Facility Director, on November 15, 2012, at 2:50 p.m., in the conference room, confirmed the facility failed to follow the Physician's Order timely for the echocardiogram, on November 12, 2012, resulting in a three day delay for diagnostic results.

Based on medical record review and interview, the facility failed to revise the care plan for a pressure sore for one (#37) of twenty-nine residents reviewed. The findings included: Resident #37 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed a Braden Scale For Predicting Pressure Sore Risk was completed on July 20, 2012. Further review revealed the resident was at moderate risk for developing pressure sores. Medical record review revealed on July 26, 2012, the resident developed two stage 2 pressure sores on the left ankle with Physician order [REDACTED]. Medical record review of the Nursing Interim Care Plan dated July 26, 2012, revealed no documentation to address the resident's pressure sores and wound care. Interview with the Director in the conference room, on November 15, 2012, at 9:00 a.m., confirmed the care plan had not been revised to include the two Stage 2 pressure sores and wound care.

Based on medical record review, review of facility policy, and interview, the facility failed to ensure the admission orders [REDACTED]. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the facility's standing admission orders Physician Signature, Date, and Time" each followed by a line to be completed by the prescribing physician. Medical Record review revealed the admission orders [REDACTED]. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical Record review revealed the admission orders [REDACTED]. Review of the facility policy number HIM.MR.010 titled Physician Orders Transcription revealed, "Diagnostic and therapeutic orders shall be written legibly in ink or typewritten and shall be dated, timed, and signed." Interview with the Director of the facility at the nurses' station on May 22, 2011, confirmed the facility failed to ensure the medical records were completed by the physicians.

Based on medical record review, observation, and interview, the facility failed to apply device to prevent blood clots as order by the physician to one (#5) of nine residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical Record review of the admitting orders dated May 18, 2011, revealed an order for [REDACTED]." ([MEDICAL CONDITION] are intermittent compression devices applied to the legs to prevent blood clots.) Observation on May 22, 2011, at 10:00 a.m., 1:20 p.m., and at 3:10 p.m., revealed resident #5 lying flat in bed in no acute distress. Observation revealed the [MEDICAL CONDITION] device was not in the resident room. Interview in the resident room on May 22, 2011, at 3:10 p.m., with the nurse assigned the care of resident #5 (Registered Nurse RN #1) verified the devices were not in the room and thus not applied to the resident. Interview with the Nurse Manager on May 24, 2011, at 8:10 a.m., in the conference room, confirmed the facility failed to apply the device as ordered.