W D Bill Manning Tennessee State Veterans Home

In the surveyor’s words

From the most serious findings on record at W D Bill Manning Tennessee State Veterans Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Nov 17, 2021

  Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, Time and Attendance Reports, staff screening logs, and interview, the facility failed to properly prevent and/or contain COVID-19 when 53 of 173 staff members (Environmental Services Staff #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13, Registered Nurse (RN) #1, #2, #3, and #4, Licensed Practical Nurse (LPN) #1, #2, #3, #4, #5, #6, #7, and #8, Certified Nursing Assistant (CNA) #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, and #29) failed to complete screenings prior to working on 13 of 13 days (10/29/2021, 10/30/2021, 10/31/2021, 11/1/2021, 11/2/2021, 11/3/2021, 11/4/2021,11/5/2021, 11/6/2021, 11/7/2021,… […]

• No harm, potential for more than minimal, patternF689Nov 17, 2021

  Based on policy review, observation, and interview, the facility failed to ensure the environment was free of accident hazards when unsecured sharps were observed in 4 of 68 resident rooms (Room #4, #16, #15, and #19) for 6 of 103 sampled residents (Resident #4, #11, #42, #68, #98, and #106) observed for accident hazards. The findings include: Review of the facility's policy titled, .Accident Policy, dated 5/30/2018, revealed .The [Named Long Term Care Facility] will strive to ensure that Residents environment remains as free of accident hazards as possible .Accident refers to any unexpected or unintentional incident, which may result in injury or illness to a Resident .Avoidable accident means that an accident occurred because a facility failed to identify environmental hazards, identify… […]

• No harm, potential for more than minimal, isolatedF880Jun 3, 2026

  Based on policy review, medical record review, observation, and interview, the facility failed to maintain and ensure the prevention and spread of infection when 1 of 7 (Licensed Practical Nurse (LPN A) nurses failed to wear Personal Protective Equipment (PPE) during medication administration for 1 of 9 (Resident #15) sampled residents reviewed. The findings include: 1. Review of the facility policy titled, Infection Control Manual .Enhanced Barrier Precautions (EBP), revealed dated 4/25/2024, revealed .Enhanced Barrier Precautions[EBP] refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] expand the use of PPE [Personal Protective Equipment] to donning of gown and gloves during high contact resident care activities that provide… […]

• No harm, potential for more than minimal, isolatedF656Oct 19, 2023

  Based on policy review, medical record review, observation, and interview, the facility failed to revise care plans for 2 of 24 (Resident #16, and #91) sampled residents reviewed for care planning. The findings include: 1. Review of the facility's policy titled .Clinical Comprehensive Care Plan Policy, dated 3/1/16 (2016), revealed .information gathered from the Minimum Data Set [MDS], family and Resident interview/assessments to develop, review and revise the Resident's Comprehensive Plan of Care. […]

• No harm, potential for more than minimal, isolatedF880Oct 19, 2023

  Based on policy review, observation, and interview, the facility failed to ensure proper infection control practices when 1 of 14 staff members (Certified Nursing Assistants (CNA) #7) handled the residents food with bare hands, when 1 of 14 staff members (CNA #2) placed a dirty tray back on the tray cart with clean trays, and when 1 of 14 staff members (CNA #5) failed to perform hand hygiene during dining observation. The findings include: 1. Review of the facility's policy titled .Handwashing/Hand Hygiene, dated 4/4/2018 revealed .Hand washing/hand hygiene is regarded by this organization as the single most important means of preventing the spread of infections. Most germs that cause serious infections in healthcare are spread by people's actions. […]