The Waters Of Smyrna, Llc

During an interview on 6/12/2024 at 4:35 PM, the Activity Director stated, .[Named Resident #15] can't remove the tray .she gets angry and frustrated and will try to climb out of the chair .I don ' t know of any set time to release the tray .I haven't been told to remove it during activities .I never see her without the tray .

During an interview on 6/12/2024 at 5:15 PM, LPN W stated, .I don't know why [Named Resident #15] has the tray across her .I would consider that tray a restraint .she can't remove it .I thought nursing homes quit using those [restraints] years ago .

During an interview on 6/13/2024 at 9:05 AM, the Physical Therapy Director stated, .today is the first time I have evaluated [Named Resident #15] for a sitting device [Rocking recliner wheelchair that can tilt back 30 degrees] .

During an interview on 6/13/2024 at 10:10 AM, the MDS Coordinator was asked why the Quarterly MDS does not reflect the use of a chair that prevents rising.

The MDS Coordinator stated, .well, she didn't have the tray on all the time .

During a telephone interview on 6/20/2024 at 11:46 PM, the facility Nurse Practitioner (NP) stated a table tray could be placed in front of a resident if the resident had the mental capacity to remove it themselves.

When asked if Resident #15 had the mental capacity to remove a tray table, the NP replied, No, Resident #15 does not have the mental capacity to remove a table tray.

During an interview on 6/21/2024 at 12:40 PM, the Wound Care Nurse (WCN) stated Resident #15 tried to get up from the geriatric chair with a table tray connected and sustained a skin tear to the front right lower leg on 3/10/2024.

The WCN stated the skin tear was healing when Resident #15 reinjured the same skin tear on 4/6/2024 trying to get out of the geriatric chair with the table tray connected.

Continued interview revealed the WCN was asked why Resident #15's arm was wrapped with gauze.

The WCN replied, There is nothing wrong with her [Resident #15] arm.

Some nurse wrapped it because she [Resident #15] had some swelling to her elbow.

When asked about the bandage on Resident #15's leg, the WCN replied, Her [Resident #15] skin tear was from the [named] geriatric chair.

During an interview on 6/21/2024 at 1:15 PM, the MDS Coordinator stated she could not find any documentation related to an assessment, physician's order, or monitoring of the table tray connected to the geriatric chair of Resident #15.

445502 06/21/2024

The Waters of Smyrna, LLC 202 Enon Springs Road East Smyrna, TN 37167

Review of medical records revealed Resident #9 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses which included End Stage Renal Disease, Dependence on Renal Dialysis, Acquired Absence of Right Leg Above the Knee, and Type 1 Diabetes Mellitus.

Review of the admission MDS assessment dated [DATE], revealed Resident #9 had a BIMS score was 15 which indicated no cognitive impairment.

Continued review revealed Resident #9 requires the use of a wheelchair, had been occasionally incontinent of Bowel and Bladder, had a surgical wound, and required dialysis.

Review of the undated Care Plan for Resident #9 revealed, Resident #9 was .at risk for an alteration in comfort related to diabetic polyneuropathy, chronic pain and Right AKA (above the knee amputation) .4/12/2024 surgical wound to right AKA .impaired visual function .legally blind .

Review of the police report dated 4/29/2024 at 4:18 AM, revealed Resident #9 submitted a report alleging neglect of an Elderly or Vulnerable Adult.On 4/29/2024 Family Member (FM) ZZ called local law enforcement related to a welfare check at [named facility's address]. Resident #9 was crying .she feared retaliation from staff for speaking out against them [the staff].

Named Resident #9 attempted to contact her nurse [LPN B] started at midnight and she was not available no one else could access the medication.

The nurse appeared shortly after the police had arrived at the facility .Resident #9 alleged the facility was the cause of her lower limb amputation .

During an interview on 6/20/2024 at 12:24 PM, the Nurse Practitioner (NP) stated Resident #9 was a medically complex resident. Resident #9 was a brittle Diabetic, required dialysis and has had an amputation. Resident #9 psychologically had concerns with depression, anxiety and a lack of social support.

The NP remembers being told about a time when Resident #9 had not been given her medication on the night shift but did not recall any pertinent details.

During an interview on 6/17/2024 at 3:20 PM, LPN B stated Resident #9 had prescription for Vistaril (medication has been used for anxiety, nausea, vomiting and itching) that was requested more often than prescribed. LPN B said the technicians were intercepting Resident #9's phone calls for her because the medication was not available. LPN B stated the prescription had been changed from every 4 hours and Resident #9 was still requesting it be given that often.

During an interview on 6/18/2024 at 10:00 AM.

The Regional Director of Operations (RDO) stated he had reviewed the police report initiated by Resident #9 and noticed there was an allegation of neglect.

The RDO stated the allegation should have been reported to the SSA within the 2-hour window.

The RDO confirmed the allegation was not reported.

445502 06/21/2024

The Waters of Smyrna, LLC 202 Enon Springs Road East Smyrna, TN 37167

During an interview on 6/12/2024 at 4:16 PM, the Activities Director stated, .I've been having issues with [Named Resident #10] for over a year now. [Named Resident #10] places his hands wherever he can on female residents such as hands, legs, and thighs.

Then tells them you know you want it. I've witnessed those incidents during activities.

Female residents are afraid of him. I reported everything that occurred to the Administrator and DON. I was told that as long as he doesn't hurt anyone there's nothing they can do. I tried to put a seating chart in place so that [Named Resident #10] wasn't close to the female residents, but he [Resident #10] didn't like or agree with that .I witnessed [Named Resident #10] putting his hand on and rubbing [Named Resident #7]'s knee. I kept a log of the incidents involving [Named Resident #10] and gave it to the DON in a folder. [Named Resident #10] knows that it is wrong. I was told by the Administrator that I can't ask him to leave activities because he has a right to be there. It was also reported to me by [Named Resident #18] that [Named Resident #10] came into her room and demanded he kiss her. [Named Resident #10] has threatened to burn the building down and was looking for matches, and nothing was done.

The Administrator and DON are well aware of the issues with [Named Resident #10] .

During an interview on 6/13/2024 at 10:50 AM, the Social Services Director (SSD) stated, .I have had concerns brought to me regarding [Named Resident #10] about the things he says and does. [Named Resident #10] came to me about not liking assigned seating, and I told him [Named Resident #10] that no one could keep him from activities .

During an interview on 6/13/2024 at 1:00 PM, the DON stated, .[Named Administrator] is the abuse coordinator. I would consider a resident attempting to kiss another resident without permission sexual abuse. [Named Resident #10] was sent out last night [6/12/2024] to the hospital for psychological evaluation due to behaviors .

The DON was asked what type of behavior was Resident #10 sent out for.

The DON responded, .I believe it was for attempting to kiss another resident .

The DON was asked when did the incident occur involving the kiss.

The DON stated the day before [6/11/2024].

The DON was asked if she had been given a folder by the Activities Director regarding all the incidents and behavior involving Resident #10.

The DON stated, .I will go look for it in my office .

During an interview on 6/14/2024 at 2:00 PM, the DON stated that she could not find the folder that was given to her by the Activities Director documenting the incidents and behaviors of Resident #10 during activities.

445502 06/21/2024

The Waters of Smyrna, LLC 202 Enon Springs Road East Smyrna, TN 37167

Review of the Care plan dated 12/5/2024, revealed, .Interventions .1/13/2024 Have resident up in

The care plan does not reflect the use of the physical restraint, the medical condition for the use, or when the restraint will be released as noted per the facility policy.

Observation on 100/200 hall at the nurse's station on 6/11/2024 at 9:50 AM, 10:46 AM, 12:22 PM, 2:10 PM, 2:20 PM, 3:00 PM, 4:04 PM, and 4:45 PM revealed Resident #15 was sitting in a geriatric chair (a large padded supportive recliner that can be placed in upright position or reclined) with a connected tray across her.

Observation at the 100/200 hall nurses' station on 6/12/2024 at 11:18 AM, revealed Resident #15 was sitting in the hallway in a geriatric chair with a tray across her. Resident #15 was unable to release the table tray and get up out of the geriatric chair without assistance.

During an interview on 6/11/2024 at 4:20 PM, the MDS Coordinator stated Resident #15 received the geriatric chair a week after she came to the facility.

The MDS Coordinator was asked what were the risk factors when placing Resident #15 in a geriatric chair with a tray secured over her.

The MDS Coordinator stated, .it could be considered a restraint .

The MDS Coordinator stated no one documented the tray had been released and had never known of her (Resident #15) asking to remove the tray.

Continued interview revealed the facility had not completed a device assessment.

During an interview on 6/12/2024 at 7:52 AM, the Director of Nursing (DON) was asked if the facility could physically restrain a resident at the family's request.

The DON stated, No.

The DON was then asked the medical symptom for the physical restraint.

The DON stated Resident #15 had the geriatric chair for previous falls and behaviors upon admission.

The DON was asked what the benefits of the physical restraint are.

The DON stated it was for keeping Resident #15 safe and prevent falls.

Further interview revealed the DON was unable to provide a physician's order, any assessments, consent for the use, or documentation of removal and timing of the release for the physical restraint.

During an interview on 6/13/2024 at 10:10 AM, the MDS Coordinator was asked why the Quarterly MDS does not reflect the use of a chair that prevented Resident #15 from rising.

The MDS Coordinator stated, .well she didn't have the tray on all the time .

During an interview on 6/21/2024 at 1:15 PM, the MDS Coordinator stated she could not find any documentation related to an assessment, physician's order, or monitoring of the table tray connected to the geriatric chair of Resident #15.

When asked if she went out to do the assessment of the restraint, the MDS Coordinator stated, I do not go out myself to do the assessment, I go by what is charted.

During an interview on 6/21/2024 at 4:05 PM, the Regional [NAME] President (RVP) Clinical Services stated the facility did not have a MDS policy and the coordinator should follow the RAI manual for the MDS.

445502 06/21/2024

The Waters of Smyrna, LLC 202 Enon Springs Road East Smyrna, TN 37167

my room and demanded I give him a kiss.

Then, he proceeded to come toward me. I yelled for him to

the incident .

445502 06/21/2024

The Waters of Smyrna, LLC 202 Enon Springs Road East Smyrna, TN 37167

During a telephone interview on 6/18/2024 at 10:07 AM, RN X was asked the reason for giving Resident #15 Ativan. RN X chuckled and replied, I gave it for agitation.

That is the only time I would give this medication.

When asked about the physician's order that read to give for seizure activity, RN X replied, [Named Resident #15] gets upset and her hands start shaking.

That is the seizure activity, and that's when we give it.

That's what hospice told me to do. I have learned since then; the activity usually happens when she needs to go to the bathroom.

Now we do that first instead of giving the medicine right away. RN X was asked if the physician was notified if the resident was having seizure activity. RN X replied, No. I do not notify the physician about the seizures.

Hospice said if we have to give her more than 2 or 3 doses a day, then we could give them a call.

During a telephone interview on 6/18/2024 at 10:21 AM, the Pharmacist stated Resident #15 had an order for Lorazepam since 12/5/2023 and was prescribed by Hospice MD.

When asked what the recommended mode of transmission for lorazepam would be related to seizures, the Pharmacist replied, .For seizures, generally it is injectable or cream. It would be hard to give a patient a PO [by mouth] lorazepam if they were having a seizure .

The Pharmacist then stated the lorazepam 2 mg injectable would typically be available in the Cubex (a medication dispenser for controlled substances), however there was none available at that time per the Pharmacist.

During a telephone interview on 6/18/2024 at 11:45 AM, the Hospice Medical Doctor [MD] stated she did order Lorazepam 2 mg for seizures but would be concerned if the nurses are not charting seizure activity when giving this medication.

Continued interview revealed Resident #15 should have 3 active orders for Lorazepam.

One for 2 mg for seizure activity, one for 2 mg for agitation, and one for 0.5 mg BID.

During a telephone interview on 6/18/2024 at 2:50 PM, MD FF stated he signed off on some of the hospice orders. MD FF was asked if he felt lorazepam 2 mg PO was the correct mode of transmission for a resident with seizures. MD FF replied, .The lorazepam PO can be given after the seizure is over and not during the active phase .

When asked if staff consistently charted 0 for a pain level, would prn pain meds need to be given. MD FF stated, If it consistently a 0, then no.

However, if they are without the pain medication, the pain could come back and potentially become worse.

The pain meds keep the patient comfortable.

During a telephone interview on 6/20/2024, the facility Nurse Practitioner [NP] stated she was not notified about Resident #15's seizure activity, but the nurses would also call hospice for any concerns or request.

When asked about giving Ativan 2 mg PO for seizures, the NP stated, Not for active seizures. It should be given IM in my professional opinion.

445502 06/21/2024

The Waters of Smyrna, LLC 202 Enon Springs Road East Smyrna, TN 37167

During an interview on 6/14/2024 at 11:33 AM, Licensed Practical Nurse (LPN) O stated there were

asked what a reasonable time for a call light to be answered and she replied, A call light should be answered within 5 minutes.

During a telephone interview on 6/18/2024 at 2:50 PM, CNA KK was asked if the night shift had ever worked short before. CNA KK replied, .We have worked with 3 people at night before .

When asked if she felt this was enough staff to care for the residents at night, CNA KK replied, No. It makes it very hard to care for all the residents and their needs.

During an interview on 6/21/2024 at 10:31 AM, CNA LL stated there were more call outs on the weekend, which made it hard to find staff to come in.

445502 06/21/2024

The Waters of Smyrna, LLC 202 Enon Springs Road East Smyrna, TN 37167

During an interview on [DATE] at 1:15 PM, the MDS Coordinator confirmed she was unable to find any documentation related to an assessment, physician's order, or monitoring of the table tray connected to the geriatric chair of Resident #15.

Observation at the 100/200 nurses' station on [DATE] at 2:10 PM, revealed Resident #15 was sitting in the geriatric chair pulling on the tray with both hands and raising her buttocks off the seat.

The staff failed to respond to Resident #15 pulling on the tray table and raising her buttocks off the seat.

Observation in the dining room on [DATE] at 3:00 PM, revealed Resident #15 was sitting in the geriatric chair with a tray table across the resident during a movie. Resident #15 was observed pulling on the tray and lifting her buttocks off of the seat. No staff responded to the Resident #15.

445502 06/21/2024

The Waters of Smyrna, LLC 202 Enon Springs Road East Smyrna, TN 37167

Observation on 6/11/2024, in the 200 Hall nourishment room at 12:35 PM, revealed a container of

Sweetened Tea with delivery date of 4/2/2024 with no open date.

The refrigerator temperature log labeled May 2024 had 1 temperature recorded and 30 days with no temperature recorded.

Observation and interview on 6/11/2024 at 1:35 PM, during a walking round with the Dietary Manager (DM), revealed outdated items were identified in 3 of the 3 nourishment rooms which included [Named nutritional supplement], thickened sweet tea, and fruit juice.

The Dietary Manager stated those items should not have remained in the refrigerator.

The ice machine in the 400 Hall nourishment room contained pink colored debris on the white surface inside the ice machine and this was confirmed present by the DM.

Observation and interview on 6/11/2024 at 1:42 PM, was conducted in the Nourishment Room on the 400 Hall with the Director of Nursing (DON).

The DON confirmed the debris in the ice machine and stated it should not have been there.

Observation and interview on 6/11/2024 at 2:05 PM, revealed the Administrator was present in the 400 Hall nourishment room and the Maintenance Director walked in as well.

The Administrator instructed the Maintenance Director to take the ice machine out of service.

Observation on 6/14/2024 at 11:10 AM, revealed the refrigerator in the 200 Hall Nourishment Room had an open container of nutritional supplement with delivery date of 4/2/2024, with no open or use by date, and continued to have brown debris in the bottom of the refrigerator.

Observation on 6/17/2024 at 10:25 AM, in the nourishment room located between the 100 and 200 Hall, revealed there was an open container of thickened sweet tea with delivery date of 6/2/2024 that had no open date and no use by date.

Observation on 6/17/2024 at 10:30 AM, in the nourishment room behind the 200 Hall desk, revealed the brown debris continued to be at the bottom of the refrigerator.

Observation on 6/17/2024 at 10:35 AM, revealed in the 400 Hall refrigerator there continued to be 4 opened condiment bottles with no label and no open or use by date on them.

The ice scoop was observed in the ice chest.

Observation on 6/17/2024 at 11:00 AM, revealed the refrigerator in the 200 Hall Nourishment Room remained soiled with the brown debris at the bottom under the drawers and had not been cleaned.

Review of the facility policy titled, GUIDELINES FOR PHYSICIAN ORDERS-(FOLLOWING PHYSICIAN ORDERS), dated 6/18/2023, revealed, .Policy: It is the policy of the facility to follow the orders of the physician .The facility will have orders to provide essential care to the resident, consistent with the resident ' s mental and physical status upon admission .Procedure: 1) c.

Routine care to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan .2) As assessments are completed, orders will be received from the physician to address significant findings of the assessment .4) All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility as the orders are received .

Review of the facility policy titled, Dressing Change, Clean, dated 1/1/2024, revealed, .ASSESSMENT GUIDELINES: General condition of skin .Mobility status .CARE PLAN DOCUMENTATION GUIDELINES .

Consider listing possible risks and complications .Identify the cause of the condition .

445502

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 445502 B.

Wing 06/21/2024

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

The Waters of Smyrna, LLC 202 Enon Springs Road East Smyrna, TN 37167