Robertson County Health Care Facility

In the surveyor’s words

From the most serious findings on record at Robertson County Health Care Facility, in the surveyor’s own words.

• Actual harm, isolatedF600Apr 1, 2025

  Based on interview, record review, and review of the facility's investigation and policy, it was determined the facility failed to protect 2 of 15 sampled residents from resident-to-resident abuse, Resident (R) 2 and R5. 1. On 10/13/2024, R2 entered R5's room uninvited and R5 was heard by staff yelling get out of my room. R2 was care planned for wandering, cussing at staff, and physical behaviors. When the State Registered Nurse Aide (SRNA) 5 responded to R5's call for help, she found R2 with her foot on R5's wheelchair. R5 reported R2 swung at her and hit her on the arm causing a skin tear and a bruise. 2. On 10/21/2024, a second incident occurred between R2 and R5. Staff observed R5 following R2 earlier that day [on 10/21/2024] and told the resident to stop. […]

• No harm, potential for more than minimal, isolatedF761Jul 2, 2025

  Based on observation, interview, record review, review of manufacturer's instructions for use, and review of the facility's policy, it was determined the facility failed to ensure insulin pens that required refrigeration were stored in the refrigerator for 1 of 5 medication carts. The findings include: Review of the facility's policy titled, Medication Storage, dated 08/04/2024, revealed medications requiring refrigeration were stored in the refrigerator. Review of the manufacturer's instructions for the Basaglar KwikPen (insulin glargine, used to decrease blood sugar) at www.insulins.lilly.com/basaglar revealed to store the unopened pen in the refrigerator at 36 degrees Fahrenheit (F) to 46 degrees F until the expiration date and at room temperature for 28 days. […]

• No harm, potential for more than minimal, isolatedF880Jul 2, 2025

  Based on interview, record review, and review of the facility's policy, the facility failed to ensure a system for controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services was maintained for 1 of 5 sampled employees, Assistant Director of Nursing/Registered Nurse (ADON/RN) 2. Review of the [State] Department for Public Health Tuberculosis (TB) Risk Assessment for ADON/RN2 revealed she had not had a TB risk assessment or tuberculin skin test since 06/19/2024. […]

• No harm, potential for more than minimal, isolatedF625Apr 1, 2025

  Based on interview, record review, document review, and review of the facility's policy, the facility failed to offer the resident and her representative an offer, in writing, of a bed hold before transferring and subsequently discharging Resident (R) 5 from the facility. In addition, the facility failed to recognize the resident's right to have access to a bed hold during her hospital stay for up to 14 days, regardless of the bed hold agreement. The findings include: Review of the facility's document Transfer and Discharge, undated, revealed the bed reservation and bed-hold policy that explained the rights of a resident up to 14 calendar days for hospital admissions. […]