Mt Pleasant Healthcare And Rehabilitation

F-F727

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 17 445374 Department of Health & Human Services Printed: 09/04/2025 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 445374 B. Wing 03/20/2025

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

MT Pleasant Healthcare and Rehabilitation 904 Hidden Acres Dr Mount Pleasant, TN 38474

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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44724

Residents Affected - Few Based on the facility policy, Facility Assessment review, Chapter 1000-02 Rules and Regulation of the Licensed Practical Nurses Rules and Regulations review, employee file review, medical record review,

observation and interview, the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely for 2 of 2 (Resident #50 and Resident #63) sampled residents with PICC lines (Peripherally Inserted Central Catheter inserted into the arm and threaded into a large vein near the heart).

The findings include:

1. Review of the facility policy titled, Nursing Services and Sufficient Staff, dated 1/23/2025 revealed, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident .The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessments and described in the plan of care .

2. Review of the facility policy titled, Facility Assessment, revised 1/25/2025 revealed, .The facility assessment will, at a minimum, address or include .care required by the resident population, using evidence-based, data-driven methods .staff competencies and skill sets that are necessary to provide the level and types of care needed .

3. Review of CHAPTER 1000-02 RULES AND REGULATIONS OF LICENSED PRACTICAL NURSES dated 10/2024, revealed 1000-02-.02 (3), .Licensed Practical Nurses shall not administer the following fluids/medication/agents or drug classifications in the context of intravenous therapy .Titrated medication and dosages calculated and adjusted by the nurse based on patient assessment and/or interpretation of lab values . and 1000-02-.02 (4) (a) 1.The Licensed Practical Nurse administers IV [Intravenous] push medications in peripheral lines [flexible tube inserted into a vein in the arm, hand, leg, or foot] only .

4. Review of the medical record revealed Resident #50 admitted on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses which included Osteomyelitis of Vertebra (bone infection of the spinal column), lumbar region.

Review of the Admission Minimum Data Set (MDS) dated [DATE REDACTED], revealed Resident #50 was receiving IV medications over the last 7 days.

Review of the Physician Order Report dated 2/20/2025-3/20/2025 revealed an order for PICC line for Antibiotic (ATB) infusion with start date 3/12/2025. Continued review revealed an order for Vancomycin (Antibiotic given that may require blood levels to monitor dosage) 1,250 mg (milligram) intravenous with start date of 1/28/2025 and Ceftriaxone (antibiotic) 2 gm (gram) intravenous with start date of 2/27/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 17 445374 Department of Health & Human Services Printed: 09/04/2025 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 445374 B. Wing 03/20/2025

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

MT Pleasant Healthcare and Rehabilitation 904 Hidden Acres Dr Mount Pleasant, TN 38474

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 0726 Review Hospital #1's Discharge Instructions dated 2/27/2025 for Resident #50 revealed, .You [Resident #50] are going home with a peripherally inserted central catheter (PICC) . Level of Harm - Minimal harm or potential for actual harm Review of the Medication Administration History dated 3/1/2025-3/20/2025 revealed Daptomycin (Vancomycin) and Ceftriaxone (Rocephin) 2 gm was administered intravenously via PICC line by Licensed Residents Affected - Few Practical Nurse (LPN) LPN L on 3/7/2025, 3/13/2025, 3/15/2025 and LPN M administered Daptomycin and Ceftriaxone intravenously via the PICC line on 3/15/2025 and 3/19/2025.

5. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE REDACTED], with diagnoses which included Osteomyelitis, unspecified and Charcot's (a progressive condition causing the bones and joints in the foot to degenerate) joint, right ankle and foot.

Review of the MDS dated [DATE REDACTED] revealed Resident #65 had an IV access over the last 7 days.

Review of the Physician Order Report dated 2/20/2025 - 3/20/2025 revealed an order for PICC line dressing change per RN (Registered Nurse) every 3 days. Continued review revealed and order for Vancomycin 750 mg intravenous per venous catheter every 12 hours with start date of 3/15/2025.

Review of the Medication Administration History dated 3/1/2025-3/20/2025 revealed Vancomycin 750 mg was administered intravenously through PICC line by LPN L on 3/17/2025 and 3/18/2025 and LPN M administered Vancomycin via the PICC line on 3/19/2025 and 3/20/2025.

During an observation and interview on 3/19/2025 at 8:45 AM LPN M stated, .[Named Resident #50] has a PICC line and receiving Rocephin 2 gm, she has been here for 3 weeks, she is receiving the medication for Osteomyelitis of her Spine post her surgery . During the interview a lab tech informed LPN M she was unable to obtain the Vancomycin trough (lowest level of the drug in the resident's body to monitor the antibiotic) on Resident #65, the nurse informed the lab tech to let the Director of Nursing (DON) know on her way out so

the DON could try and draw the lab from her PICC line. The LPN stated, .the lab comes every Wednesday to draw troughs . The LPN was asked if she could access a PICC line and she stated, .Yes I can hang the IV, but I can't draw blood from the port . The nurse put on her protective gown prior to going into the room to hang the Rocephin, she prepared the IV medication to hang on IV pole, flushes the tubing line and uses a dial a flow to set the rate, the nurse flushed the PICC line port with 10 ml [milliliters] of normal saline flush per

a 10 ml syringe, hung the Rocephin, verified the IV antibiotic was dripping and the resident was ok.

During an interview on 3/20/2025 at 8:52 AM, LPN L was asked if she had administered Vancomycin through [Named Resident #50 and Resident #65]'s PICC line. LPN L confirmed she had accessed the PICC line and ?performed the Vancomycin ?for [Named Resident #50 and Resident #65]. LPN L was asked if she had been through an IV certification course. LPN L stated, .I haven't gone anywhere for that. I don't remember any extra training I received here at the facility? .?

During an interview on 3/20/2025 at 5:00 PM, the DON was asked if LPNs could access PICC lines and hang IV antibiotics. The DON stated, .LPNs can do anything but hang blood products or push medications.

They can and have been trained. I have skill check offs; we provide training and skill check offs .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 17 445374 Department of Health & Human Services Printed: 09/04/2025 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 445374 B. Wing 03/20/2025

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

MT Pleasant Healthcare and Rehabilitation 904 Hidden Acres Dr Mount Pleasant, TN 38474

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 0726 6. Review of Licensed Practical Nurse (LPN) M's employee file revealed training for Peripheral IV Insertion dated 7/19/2024 with the observer's signature of Registered Nurse (RN) C. No specialized IV (intravenous) Level of Harm - Minimal harm or training for PICC lines [thin tube inserted into a vein in the arm and threaded to a large vein near the heart] potential for actual harm was found in the employee file.

Residents Affected - Few Review of LPN L's employee file revealed training for Peripheral IV Insertion dated 8/8/2024, with the observer's signature as LPN O. LPN L's employee file revealed no specialized IV training.

7. The Regional Nurse came to the conference room on 3/20/2025 at 6:07 PM and presented a copy of Chapter 1000-02 Rules and Regulation of Licensed Practical Nurses and stated, .Nothing says they cannot . referring to accessing a PICC line.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 17 445374 Department of Health & Human Services Printed: 09/04/2025 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 445374 B. Wing 03/20/2025

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

MT Pleasant Healthcare and Rehabilitation 904 Hidden Acres Dr Mount Pleasant, TN 38474

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 0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis. Level of Harm - Minimal harm or potential for actual harm 51365

Residents Affected - Few Based on facility policy review, record review, and interviews, the facility failed to maintain Registered Nurse (RN) coverage for 8 consecutive hours a day 7 days a week.

The findings included:

1. Review of the facility policy titled Nursing Services and Sufficient Staff, dated 1/23/2025 revealed, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on

the facility assessment .The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessments and described in

the plan of care .Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week .The Director of Nursing [DON] may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents .

2. Review of the facility's licensure information revealed the facility has 4 RNs.

Review of the staffing clock in and out punches for 2/15/2025, and 2/22/2025 revealed no RN coverage for 8 consecutive hours.

Review of the staffing clock in and out punches for 3/6/2025, revealed no RN coverage for 8 consecutive hours. Director of Nursing (DON) worked 8.5 hours; facility census was 64.

Review of the facility's Daily Nurse Staffing Form dated 3/6/2025, revealed there were no RNs scheduled that date.

3. During an interview on 3/20/2025 at 4:46 PM, the DON confirmed there must be RN coverage for 8 consecutive hours every day and that the DON cannot serve as a charge nurse if the facility's average daily occupancy is greater than 60.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 17 445374 Department of Health & Human Services Printed: 09/04/2025 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 445374 B. Wing 03/20/2025

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

MT Pleasant Healthcare and Rehabilitation 904 Hidden Acres Dr Mount Pleasant, TN 38474

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 44724 Residents Affected - Few Based on facility policy, observation and interview the facility failed to store all drugs in accordance with currently accepted professional principles for 1 of 4 medication storage areas.

The findings include:

1. Review of the facility policy titled, Medication Storage, with revision date 9/2024 revealed, .It is the policy to this facility to ensure all medications housed on our premises will be stored in accordance to .External Products .drugs for external use are stored separately from internal .medications .Internal Products: Medications to be administered by mouth are stored separately from other formulations ( .eye drops .).

2. During an observation and interview on 3/19/2025 at 10:56 AM, Registered Nurse (RN) L was working on

the [NAME] medication cart. RN L was asked to open the medication cart so surveyor could review the storage of medications. Continued observation revealed a bottle of antacid chewable tablets stored with eye drops and an ear wax removal bottle stored with the topical Lidocaine (topical pain medication) and Nicotine (transdermal patch used to quit smoking) patches. RN L was asked if these medications should be stored together and she stated, No.

During an interview on 3/20/2025 at 4:45 PM, the Director of Nursing (DON) was asked if oral medications should be stored with the eye drops; she stated, No. The DON was asked should an ear wax removal kit be stored with topical patches and she stated, No.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 17 445374