Rocky Top Care Center

In the surveyor’s words

From the most serious findings on record at Rocky Top Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Aug 22, 2024

  Based on facility policy review, Centers for Disease Control (CDC) recommendations and guidance review, job description review, facility assessment review, Activities of Daily Living (ADL) documentation review, facility staffing schedule review, facility staff time punch records review, medical record review, observations, and interviews, the facility's Administration failed to ensure the residents' personal laundry was handled, stored, processed, and transported in a safe and sanitary manner which had the potential to expose infectious pathogens to 85 of 90 residents whose laundry service was provided by the facility. […]

• Immediate jeopardy, widespreadF837Aug 22, 2024

  Based on facility policy review, job description review, facility documentation review, and interview, the facility's Governing Body failed to address the facility's widespread problem of unsafe and unsanitary handling, storing, and processing of the residents' contaminated and potentially hazardous personal laundry, which had the potential to expose infectious pathogens to 85 of 90 residents that utilized the facility provided laundry service. The facility's Governing Body failed to provide effective leadership and oversight of the facility's Administration to ensure COVID-19 positive employees were excluded from work for the required isolation time frame recommended by the Centers of Disease Control (CDC) to control the exposure and spread of COVID-19. […]

• Immediate jeopardy, widespreadF867Aug 22, 2024

  Based on facility policy review, job description review, facility assessment review, Quality Assurance and Performance Improvement (QAPI) Plan review, QAPI Meeting Minutes review, facility documentation review, and interviews, the facility's QAPI program failed to ensure an effective QAPI program that identified quality deficiencies, implement performance improvement activities to address quality concerns, and perform a root cause analysis related to poor infection control practices. […]

• Immediate jeopardy, widespreadF880Aug 22, 2024

  Based on facility policy review, facility assessment review, Centers for Disease (CDC) recommendations and guidance review, facility documentation review, medical record review, observations, and interviews, the facility failed to ensure residents' personal laundry was stored in a sanitary condition, and failed to ensure practices to prevent or mitigate the potential spread of infection and communicable disease were maintained through the process of handling, storing, processing, and transporting residents' personal laundry. The facility's non-compliance had the potential to affect 85 of 90 residents who resided in and whose laundry service was provided by the facility. […]

• Actual harm, isolatedF600May 18, 2022

  Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to prevent physical abuse for 1 resident (#3) of 8 residents reviewed for physical abuse. Resident #3 was the victim of a resident-to-resident altercation and sustained superficial lacerations and abrasions to both forearms, face, and a deep laceration behind the temple area of the scalp which required skin glue at the hospital emergency room , resulting in Harm for Resident #3. The findings include: Review of the facility policy Abuse & Neglect Policies & Procedures, undated, revealed Abuse is defined as wilful infliction of injury .Physical, verbal, mental . Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]