Nashville Center for Rehabilitation and Healing LL

In the surveyor’s words

From the most serious findings on record at Nashville Center for Rehabilitation and Healing LL, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Mar 16, 2023

  Based on facility policy review, observation, and interview, the facility failed to maintain clean and sanitary equipment for 1 of 3 ice machines and 2 of 2 stove drip pans. The facility also failed to properly store refrigerated foods in 1 of 2 walk-in coolers. The findings include: Review of the facility's policy titled, Sanitization, revealed, .The food service area is maintained in a clean and sanitary manner .Ice chests and coolers used to store and transport ice are cleaned regularly . […]

• No harm, potential for more than minimal, patternF732Oct 20, 2021

  Based on facility policy, observations and staff interview, the facility failed to post the CMS (Center for Medicare Services) Daily Staffing Record on 73 of 290 days in 2021. The findings included: Review of facility policy dated 7/2016 titled, Posting Direct Care Daily Staffing, revealed, .Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents .Within two (2) hours of the beginning of the shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format . […]

• No harm, potential for more than minimal, isolatedF637Mar 16, 2023

  Based on facility policy, medical record review, and interview the facility failed to determine and perform a significant change Minimum Data Set (MDS) assessment for 1 of 40 sampled residents (Resident #16) reviewed. The findings include: Review of the facility MDS/Care Plan Coordinator Job Description revealed, .MDS/Care Plan Coordinator is an experienced health care provider who ensures an accurate assessment and up-to-date care plan for all residents . Review of the Resident Assessment Instrument (RAI) Version 3.0 Manual revealed, .A significant change is a decline or improvement in a resident's status .will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . […]

• No harm, potential for more than minimal, isolatedF655Mar 16, 2023

  44724 47127 Based on facility policy review, medical record review, and interviews, the facility failed to create and provide a baseline care plan for 5 of 40 (Residents #59, #62, #100, #216, and #358) sampled residents reviewed for baseline care plans. The findings include: Review of the facility's policy titled, Care Plans Baseline, dated 11/30/2022, revealed, .A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .A comprehensive care plan may be used in place of the baseline care plan providing the comprehensive care plan is developed within 48 hours of the resident's admission and meets the requirements of a comprehensive assessment .The resident and/or record . […]

• No harm, potential for more than minimal, isolatedF657Mar 16, 2023

  44724 Based on facility policy review, medical record review, observation, and interview, the facility failed to have quarterly care plan conference meetings with the resident or resident's representative for 11 out of 40 sampled residents (Residents #19, #30, #32, #49, #57, #60, #69, #76, #77, #81, and #82). The findings include: Review of the undated facility policy, Care Plans, Comprehensive Person-Centered, revealed, .The interdisciplinary team [IDT], in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .The comprehensive, person-centered care plan is developed within seven [7] days of the completion of the required MDS [Minimum Data Set] [Admission, Annual or Significant Change… […]