Weakley Rehabilitation And Nursing Center
WEAKLEY REHABILITATION AND NURSING CENTER in DRESDEN, TN — inspection on June 29, 2024.
Found 12 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the Witness Statement by Social Services on 1/17/2024 at 4:25 PM, revealed, .resident [Resident #42] .stated resident .[Resident #166] walked into his room and picked up the phone.
Resident [Resident #166] . then knocked everything off the bedside table and spilled the water all over the floor.
Resident [Resident #166] . then hit [Resident #42] .with the glass in his hand on his left temple and cheek area. A nurse assisted [Resident #42] . with his cut [laceration] .
Review of the quarterly MDS dated [DATE], revealed Resident #42 scored a 15 on the BIMS, which indicated the Resident had no cognitive impairment. Resident #42 was independent and required minimal assist.
During an interview on 6/28/2024 at 8:30 AM, CNA E was asked to describe the incident of Resident #166 grabbing her arm and throat and threatening her. CNA E stated she tried to redirect Resident #166 and pulled up his briefs, but the Resident was very agitated and kept pulling away from her. CNA E stated she was walking Resident #166 down the hallway and the Resident was very agitated, and .grabbed my arm as hard as he could and said he was going to break if off . CNA E stated Resident #166 then grabbed her (CNA E) by the throat and said he, .was going to [F word expletive] kill me . CNA E stated at this point she [CNA E] was very upset and stated, . I just dropped everything and walked out . CNA E stated she told the charge nurse what had happened and that she (CNA E) was told to write a statement and chart the behaviors. CNA E stated, .I wrote the statement .I think I may have just left it on the nurse station, but I don't believe I charted the behaviors .I can't remember .it was all such a blur after that . CNA E stated no one interviewed her or talked about the incident.
During an interview on 6/28/2024 at 10:56 AM, the Director of Nursing (DON) stated, .he [Resident #166] was a handful .wandered . very agitated .hard to redirect .
The DON was asked what interventions were put into place.
The DON stated, . we referred him [Resident #166] to psych services .tried redirection .notified the doctor .PRN [as needed] Ativan [a medication for anxiety) for his agitation .
During an interview on 6/28/24 at 10:56 AM, the DON was asked if she felt like adequate interventions were put into place to keep staff and resident's safe.
The DON stated, .In hindsight, probably not . trying to think of him [Resident #166] particularly with him having issues coming in .we didn't do one on one . outside of putting stop signs on everyone's doors to keep him [Resident #166] from going in there .I don't know what else we could have done .other than he's [Resident #166] leaving and not coming back kind of thing again that's hindsight.
That's what we know now .
445437 06/29/2024
Weakley Rehabilitation and Nursing Center 700 Weakley County Nursing Home Road Po Box 787 Dresden, TN 38225
had a restraint.
The DON stated, She can release the belt herself .
The DON and the surveyor went to
not able to release the seat belt without being told to press the button while the DON tapped the red
undo it .
The DON was asked if there should be an order for a restraint.
The DON states, Yes, but this is a no restraint facility so we will have to figure something else out.
The DON confirmed something should have been on the Treatment Administration Record to ensure the resident was able to release the seat belt.
445437 06/29/2024
Weakley Rehabilitation and Nursing Center 700 Weakley County Nursing Home Road Po Box 787 Dresden, TN 38225
The facility failed to conduct a thorough investigation for an allegation of Employee to Resident Abuse.
The facility failed to immediately report the allegation of abuse to the Abuse coordinator.
The incident was not investigated until the day after the allegation. An incident was not completed in accordance with the facility policy.
And Adult Protective Services was not notified.
445437 06/29/2024
Weakley Rehabilitation and Nursing Center 700 Weakley County Nursing Home Road Po Box 787 Dresden, TN 38225
Review of the medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, Chronic Atrial Fibrillation, Diabetes, Dialysis, and End Stage Renal Disease.
Review of the Baseline care plan dated 11/11/2023, revealed the baseline care plan was initiated but not completed when it was left unsigned by the resident or family.
During an interview with the Minimum Data Set (MDS) Coordinator on 6/26/2024 at 2:30 PM, revealed the MDS Coordinator confirmed Resident #21's base line care plan was not signed by the resident or family within 48 hours of initial admission or hospital return.
Review of the medical record revealed Resident #369 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Pneumonia, Congestive Heart Failure, Diabetes, Hypertension, and Benign Prostatic Hypertrophy.
Review of the Baseline care plan dated 5/20/2024, revealed that the baseline care plan was initiated but not completed it was left unsigned by the resident or family.
During an interview on 6/28/2024 at 12:00 PM, the MDS Coordinator confirmed that the baseline care plans should be signed by the resident or the family.
The MDS Coordinator confirmed that Resident #369's baseline care plan was not signed by the resident or the family.
445437 06/29/2024
Weakley Rehabilitation and Nursing Center 700 Weakley County Nursing Home Road Po Box 787 Dresden, TN 38225
Review of the FALL COMMITTEE MEETING dated 5/6/2024, for Resident #11 revealed INTERVENTION: MD [medical doctor] to perform Med [Medication] Review secondary to increased confusion .
The facility was unable to provide evidence of an immediate med review performed for the resident's 5/5/2024 fall.
Review of the revisions to Resident #11's care plan dated 5/6/2024, revealed . NP [Nurse Practitioner] to assess resident.
There was no documentation to include the intervention of adding a door alarm to the bathroom door until 5 days after the 5/2/2024 fall (on 5/7/2024).
There was no evidence of how adding a door alarm to the Resident bathroom door would prevent further falls.
Review of Resident #11's Un-witnessed [Fall Report], for Fall#10 dated 5/8/2024, revealed .Called to the room per housekeeping that resident [Resident #11] was on the floor.
Observed her [Resident #11] laying on left side.
Tried to move resident but she started yelling out.
Left resident comfortably on the floor to get more assistance and called for [abbreviation for local emergency medical services (EMS)]] .resident stated she was getting her coat out [of] the closet so they could get out of facility .Resident was sent to [named hospital] .Injuries Observed at Time of Incident .left trochanter (hip) .Left ankle (outer) Level of Pain .7 .Mobility: Ambulatory with assistance .
Record review revealed Resident #11 was admitted to the hospital on [DATE] - 5/13/2024 with a Left Fractured Femur.
The Resident's family declined surgical intervention and the Resident was discharged back to the nursing facility with a 2-week Orthopedic consult and activities as tolerated.
Review of the annual MDS dated [DATE], revealed Resident #11 had a BIMS score of 2, which indicated severe cognitive impairment. Resident #11 had physical [TRUNCATED]
445437 06/29/2024
Weakley Rehabilitation and Nursing Center 700 Weakley County Nursing Home Road Po Box 787 Dresden, TN 38225
During an interview on 6/27/2024 at 2:53 PM, LPN B stated, .I can't remember much about him [Resident #166]. LPN B stated that Resident #166 wasn't in the facility very long and that she couldn't remember any behaviors. LPN B confirmed she did find him in Resident #23's bed but that Resident #23 was under the covers and Resident #166 was laying down asleep, on top of the covers next to Resident #23. LPN B was asked if she knew who the resident was that Resident #166 was documented to have .both hands on another resident's head . LPN B stated she could not remember.
During an interview on 6/28/2024 at 8:30 AM, CNA E was asked to describe the incident of Resident #166 grabbing her (CNA E) arm and throat and threatening her. CNA E stated, .he [Resident #166] was going in and out of resident rooms and I found him in another resident's [Resident #52] room with his brief down to his knees and had grabbed the other resident's [Resident #52] walker and started to [display sexually inappropriate behavior] .The resident [Resident #52] was upset and used a pillow and tried to cover him [Resident #166] up. CNA E stated she tried to redirect him and pulled up his brief, but he was very agitated and kept pulling away from her. CNA E stated she was walking Resident #166 down the hallway and the resident was very agitated, .grabbed my arm as hard as he could and said he was going to break if off . CNA E stated Resident #166 then grabbed her (CNA E) by the throat and .said he was going to [F word expletive] kill me . CNA E stated at this point she (CNA E) was very upset, . I just dropped everything and walked out . CNA E stated she told the charge nurse what had happened and that she (CNA E) was told to write a statement and chart the behaviors.
CNA E stated, .I wrote the statement .I think I may have just left it at the nurse station, but I don't believe I charted the behaviors .I can't remember .it was all such a blur after that . CNA E stated no one came to interview her or talk about the incident.
During an interview on 6/28/2024 at 10:56 AM, the Director of Nursing (DON) stated she had not heard about Resident #166 displaying sexually inappropriate behaviors with a walker in an occupied resident room.
The DON confirmed she had heard about Resident #166 becoming physically aggressive with a CNA who was attempting to redirect during behaviors.
The DON stated she had heard about the incident when Resident #166 was found in another resident's bed but stated her understanding was that Resident #166 was stopped before he could actually get into the bed.
The DON stated, .he [Resident #166] was a handful .wandered . very agitated .hard to redirect .
The DON was then asked what interventions were put into place.
The DON stated, . we referred him [Resident #166] to psych services .tried redirection .notified the doctor .PRN Ativan for his agitation .
The DON was asked if she felt like adequate interventions were put into place to keep staff and resident's safe.
The DON stated, .In hindsight, probably not .
445437 06/29/2024
Weakley Rehabilitation and Nursing Center 700 Weakley County Nursing Home Road Po Box 787 Dresden, TN 38225
Review of the facility's policy titled, Narcotic Control dated 8/2023, revealed .Each time a controlled medication is administered, the nurse must complete the Controlled Substance Inventory Record and keep a running count of medications used and medications on-hand .Verification of the quantities of controlled substances must be recorded on the Controlled Dosage System -Controlled Substance -Shift Change Count Check Sheet .
Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses Dementia, Carotid Artery Stenosis, Hypertension, Depression and Generalized Anxiety Disorder.
Review of the Physician's Order dated 6/4/2024 revealed .Lorazepam (an anti-anxiety medication) 0.5mg 1 tab three times a day .
Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses Parkinson's Disease, Diabetes Mellitus, Chronic Kidney Disease, Major Depressive Disorder, and Generalized Anxiety Disorder.
Review of the Physician's Orders dated 5/26/2024 revealed Lorazepam 0.5mg 1 tab two times a day .
- Observation and interview during medication storage review of the [NAME] Hall Med Cart on
6/26/2024 at 2:45 PM, revealed Resident #32's Lorazepam 0.5mg medication card had 29 tabs in the card and the resident's Controlled Substance Inventory Record reflected a count of 30 tabs.
When LPN C realized the count was incorrect, she started to sign the medication out on the controlled sheet. LPN C was informed that a copy was needed prior to alteration of documentation. LPN C reported that she administered the medication at 2:00 PM to the resident.
Review of Resident #22's Lorazepam 0.5mg medication card had 4 tabs in the card, but the resident's Controlled Substance Inventory Record for Lorazepam had a count of 5 tabs. LPN C confirmed that she should have signed the medications out in the controlled book when administering the medications.
During an interview on 6/26/2024 at 3:08 PM, the Director of Nursing (DON) confirmed that nursing staff should sign the medications out on the resident's Controlled Substance Inventory Record as the medications are pulled and administered.
The DON confirmed that the narcotic controlled counts should match the number of actual pill count in the medication card.
445437 06/29/2024
Weakley Rehabilitation and Nursing Center 700 Weakley County Nursing Home Road Po Box 787 Dresden, TN 38225
Based on policy review, medical record review, observation, and interview, the facility failed to
and [NAME] Cart) was left unlocked and unattended during medication administration.
The findings include:
Review of the facility's policy titled Medication Storage undated, revealed .It is the policy of this facility to ensure all medications housed on our premises shall be stored in the pharmacy and/or medication rooms .All drugs and biologicals will be stored in locked compartments .During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart .
Review of the facility's policy titled Medication Administration Policy dated 6/2024 revealed .Medication carts must be kept locked when not in use during medication pass .
- Observation during medication administration on 6/24/2024 at 4:28 PM, LPN B unlocked the
Northeast Medication Cart at the North Hall nurse's station, LPN B walked away leaving the cart unlocked and unattended while she walked down the hall to retrieve a computer mouse off another cart.
After LPN B returned to the medication cart, she walked away from the medication cart to answer the telephone at the nurse's station leaving the cart unlocked. LPN prepared medications for Resident #42 and entered the resident's room leaving the medication cart outside the resident's room unlocked and unattended.
- Random observation on 6/28/2024 at 9:02 AM, the west medication cart was noted unlocked and
unattended in the hallway, outside Resident #28's room. LPN A exited Resident #27's room and walked to the medication cart and locked the cart outside Resident #28's room.
During an interview on 6/28/2024 at 7:52 AM, the DON confirmed that the medication carts should not be left unlocked and unattended by nursing staff during medication administration.
445437 06/29/2024
Weakley Rehabilitation and Nursing Center 700 Weakley County Nursing Home Road Po Box 787 Dresden, TN 38225
During an interview on 6/28/2024 at 10:56 AM, the Director of Nursing (DON) stated she had not heard about Resident #166 displaying sexually inappropriate behaviors with a walker in an occupied resident room.
The DON confirmed she had heard about Resident #166 becoming physically aggressive with a CNA who was attempting to redirect during behaviors.
The DON stated she had heard about the incident when Resident #166 was found in another resident's bed but stated her understanding was that Resident #166 was stopped before he could actually get into the bed.
The DON stated, .he [Resident #166] was a handful .wandered . very agitated .hard to redirect .
The DON was then asked what interventions were put into place.
The DON stated, . we referred him [Resident #166] to psych services .tried redirection .notified the doctor .PRN Ativan for his agitation .
The DON was asked if she felt like adequate interventions were put into place to keep staff and resident's safe.
The DON stated, .In hindsight, probably not .
Refer to F-741
445437 06/29/2024
Weakley Rehabilitation and Nursing Center 700 Weakley County Nursing Home Road Po Box 787 Dresden, TN 38225
Based on policy review, observation, and interview, the facility failed to update and revise the
The findings include:
Review of the facility policy titled Emergency Food Supply dated 4/2022, revealed .The Dietary Manager shall maintain a 3-to-7-day supply of nonperishable foods .The emergency food is rotated/replenished every six months .
Review of the undated facility policy titled Disaster Planning revealed .Disaster Menu prepared from nonperishable foods.
This should include 3 to 7 days depending on state or local requirements .Disaster supplies should be checked routinely .
Review of the undated facility policy titled, Three-Day Disaster Menu revealed .Breakfast Day 1 Peanut Butter .Protein Bar .Day 3 Peanut Butter .Protein Bar .
Review of the undated facility 3-Day Supply list revealed no supply of peanut butter or protein bars. Observation and Interview in the kitchen on 6/25/2024 at 8:23 AM, revealed the Emergency Food Supply Menu listed peanut butter and protein bars.
Observation of Emergency Food Supply revealed that peanut butter and protein bars were not in the Emergency Stock.
The Dietary Supervisor confirmed that if food items are on the menu, they should also be in the emergency food supply.
During an Interview on 6/26/2024 at 3:34 PM, the Registered Dietician confirmed that if a food item is on the 3-day Emergency Food Supply Menu, it should be included in the 3-day Emergency Food Supply.
445437 06/29/2024
Weakley Rehabilitation and Nursing Center 700 Weakley County Nursing Home Road Po Box 787 Dresden, TN 38225
Review of the facility's policy titled, Enhanced Barrier Precautions, dated 5/30/2024, revealed .Enhanced barrier precautions, (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves during high contact resident care activities .an order for enhanced barrier precautions will be obtained for residents with any of the following .chronic wounds such as pressure ulcers .Implementation of Enhanced Barrier Precautions .make gloves and gowns available immediately near or outside of the resident's room .High-contact resident care activities include .wound care .any skin opening requiring a dressing .
Review of the medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Carcinoma of Skin, Scalp, and Neck, Dementia, Squamous Cell Carcinoma of Skin, Malnutrition, Depression, and Anxiety.
Review of the quarterly Minimum Data Set, dated [DATE], revealed Resident #28 had a Brief Interview for Mental Status score of 6, which indicated she was severely cognitively impaired.
Review of the Physician's Orders dated June 2024, revealed no order for Enhanced Barriers.
Review of the Physician's Orders dated 6/20/2024, revealed .Cleanse unstageable pressure injury to coccyx with wound cleanser, pat dry, apply calcium alginate (used to absorb excess moisture and promote healing in wound dressings), and cover with foam dressing daily every day shift .
Review of the Progress Notes dated 6/19/2024 at 1:35 PM, revealed .Skin/Wound Note .Nurse observed unstageable pressure injury to coccyx .Cleanse unstageable pressure injury to coccyx with wound cleanser, pat dry, apply calcium alginate, and cover with foam dressing daily .
During wound care observation on 6/26/2024 at 10:10 AM, revealed LPN D cut a strip of calcium alginate and dropped it onto a contaminated surface.
She then proceeded to complete the wound care for Resident #28 using the contaminated calcium alginate. LPN D also did not wear a gown during the wound care.
During an interview on 6/28/2024 at 1:40 PM, the Infection Preventionist confirmed staff should wear gown and gloves while performing wound care.
During an interview on 6/28/2024 at 1:46 PM, LPN D confirmed she should have worn PPE and disposed of dressing that was contaminated.
Review of the State Licensure Regulations, CHAPTER 0720-18 STANDARDS FOR NURSING HOMES revised July 2022, revealed at 720-18-.08 17 (c), Water distribution systems shall be arranged to provide hot water at each hot water outlet at all times.
Hot water at shower, bathing and hand washing facilities shall be between 105 F and 115 F.
445437
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 445437 B.
Wing 06/29/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Weakley County Rehabilitation and Nursing Center 700 Weakley County Nursing Home Road Dresden, TN 38225
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.