Shannondale Health Care Center

F-F760.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 445105

F-F867

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 15 445105 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 445105 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shannondale Health Care Center 7424 Middlebrook Pike Knoxville, TN 37909

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36003

Residents Affected - Some Based on facility policy review, medical record review, and interview the facility failed to ensure resident medical records were complete and accurate for 5 residents (Residents #2, #17, #18, #19, and #10) of 19 resident records reviewed.

The findings include:

Review of the facility's policy titled, Emptying a Urinary Collection Bag, dated 2001, revealed .The following information should be recorded in the resident's medical record .The amount of urine emptied from the drainage bag .

Review of the facility's policy titled, Change in a Resident's Condition or Status, dated 2001, revealed . promptly notifies .his or her attending physician .changes in the resident's medical/mental condition and/or status .Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including .information prompted by the Interact SBAR [situation, background, assessment, recommendation] Communication Form .

Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE REDACTED] with diagnoses including Cerebral Infarction, Neuromuscular Dysfunction of Bladder, Hemiplegia/Hemiparesis, and Vascular Dementia.

Review of a baseline care plan dated 11/21/2024, revealed Resident #2 had an indwelling urinary catheter.

Review of an admission Minimum Data Set (MDS) assessment dated [DATE REDACTED], revealed Resident #2 scored

a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated moderate cognitive impairment. Continued review revealed Resident #2 had an indwelling urinary catheter.

Review of a 7:00 PM-7:00 AM shift report dated 12/4/2024, revealed Resident #2's indwelling urinary catheter was changed during the shift.

Review of a nurse's note for Resident #2 dated 12/5/2024 at 11:30 AM, revealed Resident #2 reported the indwelling urinary catheter had been replaced on 12/4/2024 at approximately 11:00 PM.

Review of the medical record for Resident #2 from 11/21/2024-12/5/2024 revealed no documentation the resident's indwelling urinary catheter had been replaced.

Review of the medical record for Resident #2 revealed there was no documentation of the resident's urine output from 11/21/2024-12/5/2024.

Review of the medical record for Resident #17 revealed the resident was admitted to the facility on [DATE REDACTED] with diagnoses including Chronic Kidney Disease and Pressure Ulcer of Sacral Region, Unspecified Stage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 15 445105 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 445105 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shannondale Health Care Center 7424 Middlebrook Pike Knoxville, TN 37909

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Review of a significant change in status MDS assessment for Resident #17 dated 2/9/2025, revealed the resident had an indwelling urinary catheter. Level of Harm - Minimal harm or potential for actual harm Review of a comprehensive care plan for Resident #17 dated 2/20/2025, revealed .[indwelling urinary] catheter and is at risk for complications and UTI [urinary tract infection] .Monitor and document intake and Residents Affected - Some output as per facility policy .

Review of the medical record for Resident #17 for 1/2025-2/2025 revealed there was no documentation of

the resident's urine output.

Review of the medical record for Resident #18 revealed the resident was admitted to the facility on [DATE REDACTED], with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction.

Review of a comprehensive care plan for Resident #18, dated 1/24/2025, revealed .Indwelling [urinary] Catheter related to Pressure Ulcer .Monitor intake and output as per facility policy .

Review of an annual MDS assessment dated [DATE REDACTED], revealed Resident #18 had an indwelling urinary catheter.

Review of the medical record for Resident #18 dated 1/1/2025-2/21/2025 revealed no documentation of the resident's urine output.

Review of the medical record for Resident #19 revealed the resident was admitted to the facility on [DATE REDACTED] with diagnoses included Neuromuscular Dysfunction of Bladder and Stage 3 Chronic Kidney Disease.

Review of a quarterly MDS assessment dated [DATE REDACTED], revealed Resident #19 had an indwelling urinary catheter.

Review of a comprehensive care plan for Resident #19 dated 1/21/2025, revealed .Indwelling [urinary] Catheter related to urinary retention .Monitor/record/report to MD [medical doctor] for .no output .

Review of the medical record for Resident #19 dated 1/1/2025-2/21/2025 revealed no documentation of the resident's urine output.

Review of the medical record revealed Resident #10 was admitted to the facility on [DATE REDACTED] with diagnoses including Neuromuscular Dysfunction of the Bladder, Retention of Urine, Urinary Tract Infection (UTI), and Functional Quadriplegia.

Review of a comprehensive care plan for Resident #10 dated 3/14/2024, revealed .Potential for UTI R/T [related to indwelling catheter]. Recent CAUTI [catheter associated urinary tract infection] with sepsis, neuromuscular dysfunction of the bladder .Observe for confusion, temp [temperature], decreased output, c/o [complaint of] abd. [abdominal] or flank [either side of lower back] pain, abdominal distension, clamminess, change in LOC [level of consciousness] qs [every shift] and prn [as needed]. Report abnormal to m.d. [medical doctor] prn .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 15 445105 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 445105 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shannondale Health Care Center 7424 Middlebrook Pike Knoxville, TN 37909

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Review of a quarterly MDS assessment dated [DATE REDACTED], revealed Resident #10 had an indwelling urinary catheter. Level of Harm - Minimal harm or potential for actual harm Review of an alert note (nurse's note) dated 7/12/2024 at 1:47 PM, revealed Resident #10 reported extreme discomfort in the resident's genital area and reported a pain level of 10 (pain rating score 1-10, with 10 being Residents Affected - Some highest level of pain). The nursing supervisor was notified of the resident's complaint.Offered to change [indwelling urinary catheter] and resident declined, requesting to be transported from facility to ER [emergency room ] .

Review of the medical record for Resident #10 revealed a SBAR communication tool was not in the medical record.

During an interview on 2/21/2025 at 2:20 PM, the Director of Nursing (DON) confirmed staff were expected to document resident's urine output and indwelling catheter changes in the medical record and confirmed staff were expected to complete a SBAR communication tool for resident's who were transferred to the ER.

The DON confirmed Resident #2's urine output, and a catheter change performed for Resident #2 on 12/4/2024 had not been documented in the medical record and confirmed a SBAR communication tool was not completed when Resident #10 was transferred to theER on [DATE REDACTED].

During an interview on 2/21/2025 at 4:00 PM, the Assistant Director of Nursing (ADON) confirmed urine output had not been documented in the medical record for Resident's #17, #18, and #19.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 15 445105 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 445105 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shannondale Health Care Center 7424 Middlebrook Pike Knoxville, TN 37909

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49786

Residents Affected - Few Based on facility policy review, medical record review, facility document review, Quality Assurance and Performance Improvement (QAPI) Plan review, and interview, the facility's QAPI committee failed to ensure

an effective QAPI program that identified quality deficiencies, implemented performance improvement activities to address quality concerns, and performed a root cause analysis related to medication errors. The QAPI committee failed recognize, identify, develop and implement corrective systems to ensure appropriate care and safety by all disciplines involved in the medication transcription error. The QAPI committee failed to ensure facility wide education was conducted to ensure understanding of the transcription of hospice admission orders after a significant medication error was identified for 1 resident (Resident #7) related to the resident's Morphine orders. The QAPI committee failed to identify and implement an effective action plan to correct deficiencies when hospice orders were incorrectly transcribed on admission, and failed to identify, educate, and put action steps in place with the facility, agency and hospice staff. The QAPI committee failed to implement effective processes, to include effective training, for all facility staff nurses responsible for medication transcription orders and all agency staff nurses responsible for transcription of medication orders, as well as, education and coordination with hospice staff to ensure clear concise provider orders are sent on admission to mitigate transcription errors.

The findings included:

Review of the medical record revealed Resident #7 admitted to the facility on [DATE REDACTED] for 5 days of respite care. The hospice agency orders in place at the time of admission revealed Resident #7 was to receive Morphine Concentrate 100 milligrams (mg) per 5 milliliters (ml) or 20 mg per 1 ml, give 0.25 ml or 5 mg, every 2 hours orally as needed (PRN) for shortness of breath (SOB). On admission to the facility, Licensed Practical Nurse (LPN) A incorrectly transcribed Resident #7's order for Morphine Sulfate and the facility administered the medication on a 2-hour schedule instead of as needed. Resident #7 was administered 12 doses of morphine on 8/9/2024, 8 doses of morphine on 8/10/2024, 12 doses of morphine on 8/11/2024 and 11 doses on 8/12/2024. When Resident #7's daughter returned from her trip, Resident #7 was out of it and couldn't speak. The facility identified the medication error when it was brought to the Director of Nursing (DON) and Assistant Director of Nursing's (ADON) attention by Resident #7's daughter and LPN B changed

the order to PRN but did not change the concentration. The facility was unaware the concentration they had documented on the Medication Administration Record was still incorrect until it was brought to their attention

on survey.

Review of a Performance Improvement Plan (PIP) for the medication error put into place to address significant medication errors related to errors in transcription dated 8/13/2024, was as follows:

a. Identification of resident involved or likely to be affected.

b. Education to LPN B the staff nurse who missed the error in transcription by LPN A.

c. Interdisciplinary Team meeting to discuss hospice orders, noted the format of hospice orders and made note to look at the PRN column.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 445105 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 445105 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shannondale Health Care Center 7424 Middlebrook Pike Knoxville, TN 37909

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 d. Process for admission orders was to ensure they are checked off by the DON or ADON.

Level of Harm - Minimal harm or During an interview on 2/21/25 at 4:30 PM, the DON stated the medication error was identified by the facility potential for actual harm on 8/13/2024 by LPN C who discussed the issue with Resident #7's daughter. The DON stated the facility Medical Director (MD) was notified, a Medication Error Form was completed, an investigation was Residents Affected - Few conducted, and a PIP was put in place. The DON stated her IDT team met for QAPI to include the DON, ADON, Unit Manager, MDS Nurse, and Wound Care Nurse. The DON stated her investigation revealed Morphine Sulfate oral solution 20 mg/5 ml 0.25 ml every 2 hours was ordered and transcribed as scheduled, not PRN. The DON stated no harm came to the resident except that the patient's daughter reported her mother was drowsy. The DON stated her corrective action was to correct the Morphine order on 8/13/2024 prior to discharge but just realized today the concentration on the corrected order was incorrect. The DON stated measures taken to prevent recurrence of this incident were to educate LPN B, note the format of hospice orders and to ensure staff were looking at the PRN column. The DON stated orders were still transcribed by a staff nurse, checked by another nurse, an MRR was still completed within 3 days and now

the DON and ADON check all resident orders. The DON stated they perform routine random audits as well, but these audits were not documented anywhere, and she had no record of audits being completed. The DON stated LPN B was educated on her mistake. The DON stated she did not educate the agency nurse who transcribed the morphine incorrectly because she was not her (facility) employee. The DON stated she did not educate any other staff nurses on medication errors and did not include hospice, agency or pharmacy

in her PIP. The DON confirmed the QAPI Committee had identified a significant medication error as an area of concern for the facility but was not aware of the extent of the problem. Continued interview confirmed the facility failed to perform a root cause analysis or thorough investigation for the significant medication error as

the errors in morphine concentration were not identified even after the error was caught. Further interview confirmed the facility failed to implement an effective plan to mitigate errors in transcribing orders by not including facility or agency staff nurses responsible for transcribing orders and not communicating the need for clear concise hospice orders with the hospice agency. The QAPI Committee failed to ensure an effective Quality Assurance Program was in place to monitor and evaluate concerns related to significant medication errors.

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