Asbury Place At Maryville
Inspection history, citations, penalties and survey trends for this long-term care facility in Maryville, Tennessee.
- Location
- 936 Epworth Road, Maryville, Tennessee 37804
- CMS Provider Number
- 445017
- Inspections on file
- 26
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Asbury Place At Maryville during CMS and state inspections, most recent first.
A resident on hospice with neurocognitive disorder, dementia, anxiety, and adult failure to thrive experienced a rapid decline with labored tachypnea, tachycardia, clammy skin, and non-verbal signs of pain. A hospice nurse assessed the resident, determined the resident was actively dying, obtained urgent physician orders for Morphine, Ativan, and Hyoscyamine, and verbally instructed an LPN to obtain and administer these comfort medications from emergency stock. Although the faxed orders were successfully transmitted and emergency stock was available, the medications were never transcribed to the MAR or administered, and there was no documented ongoing monitoring after the hospice visit. The resident’s daughter and a family friend reported no assessments or medication administration during critical hours, and the DON and hospice nurse confirmed that the failure to provide the ordered comfort medications resulted in actual harm and that the resident died in agony.
Improper Food Storage and Nonfunctional Dietary Equipment: Surveyors found multiple dry storage and refrigerated food items available for resident use that were undated, unlabeled, or past use-by dates, including cereal, tortillas, wafers, cheese, and noodles. The dietary area also had a deep fryer and a reach-in refrigerator that were not operational, and the DON confirmed the foods had been stored improperly and were in violation of facility policy.
Failure to obtain informed consent for psychotropic meds was identified for four residents. Records showed residents with diagnoses including dementia, depression, anxiety, bipolar disorder, and psychosis received antipsychotic or antianxiety meds such as Quetiapine, Olanzapine, and Alprazolam, but no signed consent forms were in the chart. The ADON confirmed the missing psychotropic med consent forms.
Inaccurate MDS assessments were found for two residents. One resident had PASRR Level II findings for intellectual disability and serious mental illness, but the annual MDS did not reflect that status. Another resident had CHF documented in the chart and was receiving diuretics and other cardiac meds, but the admission MDS did not check Heart Failure as an active diagnosis; the RN MDS Coordinator confirmed both assessments were inaccurate.
Incomplete Comprehensive Care Plans for Two Residents: The facility failed to develop comprehensive care plans for two residents. One resident had PTSD, dementia, bipolar disorder, and intellectual disabilities, with a PASRR Level II outcome for intellectual disability and serious mental illness, but the care plan did not address the PASRR status. Another resident had CHF and pulmonary HTN, was receiving Lasix, metolazone, and metoprolol after a recent CHF exacerbation, but the care plan did not address the active HF diagnosis.
Care plan not updated and quarterly conference notices missing. A resident with CKD stage 5 on dialysis had a Perma Cath in the right chest, but the comprehensive care plan was not revised to reflect the device or related interventions after a physician note documented the catheter and AV fistula plan. In a separate case, a resident with CHF, dementia, and anemia had no documented quarterly care plan conference notes or invitations for the resident representative after an earlier IDT meeting, and staff could not locate the required documentation.
Unsecured medications were found in a resident’s room despite no order for self-administration. The resident had dementia and severe cognitive impairment, and surveyors observed eye drops, gas relief tablets, antacid chews, and antifungal powder left unsecured in the room; an RN confirmed the resident did not self-administer medications and that the medications were unsecured.
EBP was not followed for a resident on MDRO precautions. The resident had dementia, type 2 DM, depression, anxiety, moderate cognitive impairment, and was always incontinent of urine and bowel. During observation, a CNA entered the room, applied gloves, did not apply a gown, and provided incontinence care by changing the resident’s brief. The room had an EBP sign posted stating staff must wear gloves and gown for high-contact care activities, and the ADON confirmed the CNA failed to follow the facility’s infection control policy.
Failure to Administer Hospice Comfort Medications to Actively Dying Resident
Penalty
Summary
The deficiency involves the facility’s failure to timely transcribe and administer hospice physician comfort-medication orders for a resident who was actively dying and on hospice services. Facility policies on pain management and medication administration required prompt recognition and assessment of pain, implementation and carrying out of physician orders, and timely administration of medications, with documentation of any reason for not administering medications. The resident had diagnoses including Neurocognitive Disorder with Lewy Bodies, unspecified dementia, anxiety disorder, adult failure to thrive, and was on hospice services with a Do Not Resuscitate status. A quarterly MDS showed the resident was cognitively intact but required moderate to maximal assistance with activities of daily living. On the morning in question, the hospice nurse arrived at approximately 10:30 AM after being contacted by the resident’s daughter about a change in condition. The hospice nurse assessed the resident and documented that the resident had an expected very short life expectancy of days to one week, was near death, used non-verbal indicators of pain, had labored tachypnea at 32 breaths per minute, tachycardic and irregular heart rate at 132 beats per minute, warm and clammy skin, and no oral intake for two days. The hospice nurse determined the resident was actively dying and obtained physician orders for Morphine Sulfate, Ativan (Lorazepam), and Hyoscyamine, with scheduled and PRN dosing for comfort and secretion control. These written orders were faxed to the facility and pharmacy at 11:26 AM, marked urgent. The hospice nurse reported giving verbal orders and specific instructions to the LPN on duty to obtain the medications from the facility’s emergency stock and administer them immediately. Despite these orders and instructions, the medical record and Medication Administration Record showed no evidence that the comfort medications were transcribed into the resident’s MAR or administered at any time before the resident’s death that afternoon. Nurse’s notes by the LPN at 2:02 PM documented elevated heart rate, rapid respirations, lack of eating or drinking, and that the hospice nurse had evaluated the resident and stated the resident was actively dying, but there was no documentation of comfort-medication administration or ongoing monitoring after the hospice visit. The resident’s daughter reported observing her mother with altered mental status, faint moaning, rapid shallow breathing, pale and moist skin, and appearing in distress earlier that morning, and stated that during her absence from approximately midday until about 2:00 PM, a family friend at the bedside did not see staff assess or medicate the resident. Upon her return, the daughter questioned the LPN about the lack of Morphine or other medications and was told the medications were awaiting pharmacy delivery; the hospice nurse later informed the daughter that the medications could have been taken from the facility’s emergency stock. The former DON confirmed that Morphine, Lorazepam, and Hyoscyamine were maintained in emergency stock and could have been used immediately. The DON verified there was no evidence the ordered medications were administered, and the hospice nurse stated that the failure to administer comfort medications caused harm and, in her professional judgment, caused the resident to die in agony.
Improper Food Storage and Nonfunctional Dietary Equipment
Penalty
Summary
The facility failed to maintain safe food storage in the dietary department and failed to maintain fully operational equipment, affecting 115 residents. Review of the facility policy on sanitation and food safety required leftovers and open foods to be clearly labeled with discard dates, and specified that food items prepared in house or opened for later use must be labeled and dated according to the policy. During observation of the dry storage area, surveyors found multiple food items available for resident use that were either undated, past the manufacturer’s use-by date, or not properly labeled, including toasted oats, dry cereal, flour tortilla shells, vanilla wafers, coconut flakes, breading flakes, and dry macaroni noodles. Further observation of the walk-in refrigerator revealed a half pan of shredded Parmesan cheese with an open date but no use-by date, and a freezer bag containing a half block of American cheese with no label or use-by date, both available for resident use. In addition, the dietary department’s deep fryer was not operational and had been out of use since October 2025, and the reach-in refrigerator was also not operational and had been out of service for several months. The Dietary Manager stated she was uncertain when either piece of equipment would be repaired or replaced, and later confirmed the foods observed had been stored improperly and were in violation of facility policy.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications for 4 residents reviewed for unnecessary medications. Facility policy titled, Psychotropic Drugs Usage, stated that any resident receiving a psychotropic medication must have a signed informed consent initiated when the medication starts. Review of the medical record showed Resident #11, who had diagnoses including Alzheimer's Disease, Dementia, Panic Disorder, and Major Depressive Disorder and a BIMS score of 0 indicating severe cognitive impairment, received Quetiapine 25 mg daily and Olanzapine 5 mg daily, but no consent form was found for either medication. Resident #92, with diagnoses including Vascular Dementia, Cognitive Communication Deficit, and Lack of Coordination and a BIMS score of 6 indicating severe cognitive impairment, received Quetiapine 12.5 mg daily with no consent form in the record. Resident #4, diagnosed with Dementia with Behavioral Disturbance and Depression and with a BIMS score of 0 indicating severe cognitive impairment, received Olanzapine 5 mg twice daily without a consent form on file. Resident #77, diagnosed with Anxiety Disorder, Bipolar Disorder, Major Depressive Disorder, Psychosis, and Mood Affective Disorder and with a BIMS score of 13 indicating cognitive intactness, received Alprazolam 0.5 mg twice daily without a consent form in the record. During an interview, the Assistant Director of Nursing confirmed there were no psychotropic medication consent forms in place for Residents #11, #92, #4, and #77.
Inaccurate MDS Assessments for PASRR Status and Heart Failure
Penalty
Summary
The facility failed to ensure accurate MDS assessments for 2 residents reviewed for MDS accuracy. For one resident, the record showed diagnoses including PTSD, dementia, bipolar disorder, and intellectual disabilities, and a Notice of PASRR Level II Outcome stated the resident met criteria for intellectual disability and serious mental illness. However, the annual MDS assessment indicated the resident was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. A Nurse Practitioner progress note also documented a history of major depressive disorder, bipolar disorder, anxiety disorder, dementia, trauma/stressor related disorder, and intellectual disability, and the MDS Coordinator confirmed the annual MDS was inaccurate. For the second resident, the record showed admission diagnoses of acute on chronic diastolic congestive heart failure and pulmonary hypertension. The MAR documented administration of Furosemide, Metolazone, and Metoprolol Tartrate during the look-back period, and a Nurse Practitioner progress note documented a history of diastolic congestive heart failure and a recent hospitalization. The admission MDS showed a BIMS score of 15 and did not check Heart Failure as an active diagnosis, despite the resident receiving diuretics and having heart failure documented in the medical record. The RN MDS Coordinator reviewed the records and confirmed the admission MDS was inaccurate and did not reflect the resident's active diagnosis of Heart Failure.
Incomplete Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for 2 of 26 residents reviewed for care planning. Facility policy stated that comprehensive care plans must expand on the resident’s risks, goals, and interventions using a person-centered approach, include measurable objectives and timetables, be finalized within 7 days of completion of the full comprehensive MDS assessment, and include any specialized services or specialized rehab services recommended through PASARR. The record for Resident #6 showed diagnoses including PTSD, dementia, bipolar disorder, and intellectual disabilities, and a PASRR Level II outcome dated 3/26/2021 indicated the resident met criteria for intellectual disability and serious mental illness. However, the comprehensive care plan revised 6/17/2025 did not address the resident’s Level II PASRR status, and the MDS Coordinator confirmed this during interview. The record for Resident #84 showed diagnoses including acute on chronic diastolic CHF and pulmonary hypertension. The MAR dated 11/20/2025 through 11/30/2025 showed the resident received Furosemide 80 mg twice daily, metolazone 5 mg daily, and metoprolol tartrate 50 mg twice daily. A Nurse Practitioner progress note dated 11/21/2025 documented recent hospitalization for acute diastolic CHF exacerbation and a plan to continue diuresis with Lasix and metolazone and continue metoprolol. However, the comprehensive care plan revised 12/2/2025 did not outline or address the resident’s active diagnosis of heart failure, and the RN MDS Coordinator confirmed this during interview.
Care Plan Not Updated and Quarterly Conference Notices Missing
Penalty
Summary
The facility failed to revise the care plan for Resident #3 after a physician progress note documented removal of a Perma Cath and placement of an AV fistula, with the Perma Cath scheduled for removal on 1/22/2026. Resident #3 was admitted with chronic kidney disease stage 5, dependence on renal dialysis, and presence of vascular implants and grafts. The quarterly MDS assessment showed the resident had a BIMS score of 15 and was cognitively intact and receiving dialysis. An observation on 1/12/2026 at 1:30 PM showed the resident had a Perma Cath in the right chest, but the comprehensive care plan dated 1/13/2026 had not been revised to include the Perma Cath or related interventions. The LPN MDS Coordinator and the Regional RN both confirmed the care plan had not been updated to reflect the Perma Cath. The facility also failed to provide Resident #105 and the resident representative notice of quarterly care plan conferences. Resident #105 was admitted with diagnoses including congestive heart failure, dementia, and anemia. A care plan meeting progress note dated 3/24/2024 showed the interdisciplinary team reviewed medications, diet, and activities, and the resident representative was invited to attend, but there was no documentation of additional care plan meetings after that date. The resident's daughter stated the family wanted more involvement in care planning, and the Social Services Director and Regional RN both confirmed they could not locate quarterly care plan meeting notes, documentation, or invitations since 3/18/2024.
Unsecured Medications Found in Resident Room
Penalty
Summary
The facility failed to ensure medications were secured in one resident’s room. The facility policy on Medication Self Administration stated residents who request to self-administer drugs must be assessed at admission or later to determine if the practice is safe, based on the Resident Assessment Self-administration Tool, and the assessment results are to be discussed with the attending physician with an order obtained if appropriate. Resident #43 was admitted with diagnoses including dementia, major depressive disorder, and metabolic encephalopathy, and a PPS Part A discharge MDS assessment showed a BIMS score of 6, indicating severe cognitive impairment. The physician’s orders showed no order for the resident to self-administer medications. During observation of the resident’s room, surveyors found unsecured medications in multiple locations: liquid tear eye drops on the bedside table, extra strength gas relief tablets and antacid chews on the bathroom sink, and miconazole nitrate 2% antifungal powder in the window seal. A later observation with RN A confirmed the same medications remained unsecured in the room. RN A stated the resident did not self-administer medications and confirmed the medications were unsecured.
Failure to Follow Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
The facility failed to follow its infection prevention and control policy for Enhanced Barrier Precautions for one resident. The policy titled "GUIDELINES for ENHANCED BARRIER PRECAUTIONS" stated that EBP is an extension of PPE and that gloves and gowns are to be used for high-contact resident care activities such as changing briefs and for resident care activities involving a resident with a known MDRO. Resident #15 was admitted and later readmitted to the facility with diagnoses including dementia, type 2 diabetes, major depressive disorder, and anxiety disorder. A quarterly MDS assessment showed the resident had moderate cognitive impairment and was always incontinent of urine and bowel, and a physician order dated 12/1/2025 indicated Enhanced Barrier Precautions for MDRO.
Latest citations in Tennessee
Electronic Medical Records Left Visible on Unattended Computers: Two residents' EMRs were left open and visible on unattended computers during wound care and med pass. One resident had HTN, DM, and malnutrition with moderate cognitive impairment, and another resident had acute respiratory failure with hypoxia, HTN, DM2, and Afib with intact cognition. Staff confirmed the screens were left open and available for public view.
Medication cart security was not maintained for Cart 700. Facility policy required the cart to be locked when out of the medication nurse’s sight, but an RN walked away from the cart and later entered a resident room while leaving it unlocked and unattended. The RN confirmed the cart should have been locked, and the President of Clinical Operations confirmed carts should be locked when unattended.
Staff failed to follow diabetes management policies and provider orders for multiple residents by not consistently notifying the MD/NP of blood glucose (BG) readings outside ordered and policy-defined parameters and not documenting required treatment for hypoglycemia. One resident with Type 2 DM, severe cognitive impairment, and a high A1C had repeated episodes of severe hyperglycemia and hypoglycemia over several months, with numerous BG values above 400–500 mg/dL and below 70 mg/dL that were neither reported to the provider nor accompanied by documented administration of Glutose or glucagon. This resident later experienced altered mental status, hypotension, and a BG of 600 mg/dL, was transferred to the ED with a BG of 1025 mg/dL and diagnosed with DKA and related complications, and subsequently had a large acute to subacute cerebral infarct. Another resident on Lantus and Humalog sliding-scale insulin had multiple high and low BG readings, including values in the 40s and 50s mg/dL, without consistent documentation of hypoglycemia treatment or provider notification when thresholds were met. Similar unreported abnormal BG readings were found in other residents, leading surveyors to cite noncompliance with F684 for failure to provide appropriate treatment and care according to orders and resident needs.
The facility failed to report an allegation of staff-to-resident physical and verbal abuse to the state survey agency within the required two-hour timeframe. A resident with severe dementia, muscle weakness, and difficulty walking, who required two-person assistance for ADLs, became combative during perineal care, and multiple CNAs later reported that a CNA had roughly grabbed the resident’s arms, slammed the resident’s wrists onto the chest, used profanity, made threats, and stated the resident belonged in a psychiatric ward. These CNAs did not report their concerns immediately, and the allegation was not submitted to the state reporting agency until two days after the incident, contrary to facility policy and the expectations stated by the DON and ADM.
A resident with COPD, lack of coordination, and anxiety disorder had a prior fall with a care plan intervention for nonskid strips at the bedside. The facility later failed to keep that intervention in place, and the resident was found on the floor beside the bed after hollering for help, resulting in a left hip fracture and surgical repair. Surveyors observed the nonskid strips were not at the bedside, and the DON, ADM, LPN, and RD confirmed they were missing.
Resident Trust Funds Exceeded Medicaid Asset Limit: The facility failed to keep resident trust fund balances under the $2,000 Medicaid asset limit for multiple residents. Record review showed several residents with diagnoses including dementia, CHF, CKD, diabetes, hemiplegia, bipolar disorder, Parkinson’s disease, and traumatic subdural hemorrhage had trust fund balances ranging from $2,769.53 to $9,020.33, and both the BOM and Administrator stated the limit was under $2,000.
Unsecured and unlabeled medications were found at a resident’s bedside and in a medication cart. A resident with multiple diagnoses, including HTN and delusional disorder, had several scheduled oral meds left unattended in a clear cup on the nightstand without a self-administration order or assessment, and an LPN identified the pills as the resident’s medications. In a separate observation, an LPN and the DON found prepared, unlabeled meds left in a med cart drawer instead of being administered or otherwise secured.
A resident with dementia, seizure disorder, repeated falls, and high fall risk was care-planned for a low bed with brakes locked, a fall mat, and call light within reach, and was totally dependent on staff for transfers and bed positioning. Despite this, staff accounts indicated the bed was often kept at about waist height, and several staff reported not seeing a fall mat at the bedside. The resident was later found supine on the floor with her head and torso under the bed, the bed frame resting on her chest and head, and the corded bed remote under her back, requiring staff to raise the bed to remove her. A detective observed that a fall alert device on the bed was not plugged in and that the call light was tucked behind the nightstand, out of the resident’s reach, though it worked when tested. EMS and police documented compression marks on the resident’s torso and face consistent with the bed frame and piston. The facility’s own safety policy required implementation of interventions to reduce accident risks, but records showed no care-plan revision with additional bed-related safety measures after prior falls and no documentation that existing interventions were consistently implemented, leading surveyors to cite a deficiency for failure to prevent accidents and maintain a hazard-free environment.
A cognitively intact resident with chronic kidney disease, hypertension, and type 2 DM was struck on two occasions by another resident with severe cognitive impairment and aphasia who entered the resident’s room and hit her after being asked to leave. After the first incident, the care plan was revised to include a stop sign on the door, but staff failed to consistently maintain this intervention, including not reattaching it after an appointment and forgetting to put it back up after exiting the room. Surveyors later observed the stop sign missing and no staff in sight while the resident sat on the bed, and the resident reported that the other resident had entered her room and struck her twice and that staff did not keep the stop sign up much. Skin assessments documented transient redness but no lasting injury, and the DON confirmed that physical contact occurred on both occasions.
A resident with chronic kidney disease, essential hypertension, and type 2 DM, who was cognitively intact per MDS/BIMS, had a comprehensive care plan that required a stop sign to be maintained on the room door, with staff assistance as needed to keep it in place. During observation, the stop sign was not on the door, no staff were in sight while the resident sat on the side of the bed, and the resident reported that staff did not keep the stop sign up much anymore. An LPN admitted forgetting to replace the stop sign after leaving the room, and the DON confirmed that the care plan intervention requiring the door stop sign was not followed.
Electronic Medical Records Left Visible on Unattended Computers
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when electronic medical records were left open and visible to others. Facility policy stated resident health information must remain private and that the MAR must remain closed or covered when not in direct use. Resident #76, who was admitted with diagnoses including hypertension, diabetes, and malnutrition and had a BIMS score of 8 indicating moderate impairment, was observed on 5/11/2026 at 2:37 PM with the wound care cart unattended and the computer on top of the cart open to the resident's electronic medical record and available for public view. The wound care nurse later returned and confirmed the screen had been left open to Resident #76's record. Resident #41, who was admitted with diagnoses including acute respiratory failure with hypoxia, essential hypertension, type 2 diabetes mellitus, and paroxysmal atrial fibrillation and had a BIMS score of 13 indicating cognitive intactness, was observed during medication administration on Cart 700 on 5/12/2026 at 7:40 AM when RN A walked away from the medication cart leaving the computer open and the resident's electronic medical record available for public view. A later observation at 8:01 AM showed RN A entering a room while the computer remained open with Resident #41's electronic medical information still visible. RN A confirmed the screen was open and available for public view, and the President of Clinical Operations later confirmed the electronic medical record should not be unattended and left open for public view.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure medications were securely stored in 1 medication cart, Cart 700, out of 3 medication carts reviewed. The facility policy titled, Medication Administration General Guidelines, dated 9/18, stated that during medication administration, the medication cart is to be kept closed and locked when out of sight of the medication nurse. During observation on 5/12/2026 at 7:40 AM, RN A walked away from Cart 700, leaving the cart unlocked and unattended. During another observation on 5/12/2026 at 8:01 AM, RN A entered room [ROOM NUMBER] and again left the medication cart unlocked and unattended. RN A later confirmed she should have locked the medication cart when it was left unattended, and the [NAME] President of Clinical Operations confirmed the medication carts should be locked when left unattended.
Failure to Follow Diabetes Management Policies and Notify Provider of Abnormal Blood Glucose Levels
Penalty
Summary
The deficiency involves the facility’s failure to follow its own diabetes management policies and physician/NP orders for monitoring and responding to abnormal blood glucose (BG) levels, including required provider notification and treatment for hypoglycemia and hyperglycemia. Facility policies defined hypoglycemia as BG <70 mg/dL and required immediate provider notification and administration of rapidly absorbed glucose or glucagon, and defined thresholds for hyperglycemia that required provider contact when BG values were >250 mg/dL more than once in 24 hours or >300 mg/dL more than once over two consecutive days. For residents with sliding-scale insulin orders, the MARs also contained explicit instructions to notify the physician or NP when BG readings exceeded specified ranges (e.g., >351–400 mg/dL and above). Despite these clear parameters, staff repeatedly failed to notify the provider or document required treatment when BG readings fell outside ordered or policy-defined ranges. Resident #1, who had Type 2 diabetes, acute kidney failure, depression, anxiety disorder, and a severely impaired BIMS score of 3, had an A1C of 9.2% in November 2025 and was on a consistent carbohydrate diet with dysphagia modifications and sliding-scale insulin lispro before meals. Throughout January, February, March, and April 2026, Resident #1’s Weights and Vitals Summary reports showed numerous episodes of severe hyperglycemia (often >400–500 mg/dL and above the sliding-scale notification thresholds) and multiple episodes of hypoglycemia with BG values as low as 42–54 mg/dL. On multiple dates, there was no documentation that Glutose or glucagon was administered for BG <70 mg/dL, and there was no evidence that the physician or NP was notified when BG values exceeded the facility’s policy thresholds or the sliding-scale notification parameters. The record also showed that after the sliding-scale insulin order was discontinued, staff still did not consistently notify the provider when BG values met the facility’s policy criteria for reporting. Resident #1 subsequently experienced clinical deterioration associated with very high BG levels. A progress note on 3/16/2026 documented altered mental status, functional decline, unresponsiveness, hypotension (BP 83/42), tachycardia, and a BG of 600 mg/dL, leading to transfer to the ED. Hospital records indicated presentation with gradually worsening condition over 2–3 days, hypoxia requiring oxygen, and a BG of 1025 mg/dL, with diagnoses including diabetic ketoacidosis (DKA), acute kidney injury, UTI, acute toxic metabolic encephalopathy, and hypotension, and treatment with an insulin drip in the ICU. After return to the facility, Resident #1 continued to have unreported hypoglycemic readings (e.g., 67–69 mg/dL with no documented Glutose or glucagon) and further episodes of severe hyperglycemia that met policy thresholds for provider notification but were not reported. Later in March, the resident was again sent to the hospital with left-sided weakness and facial droop, and imaging showed a large acute to subacute infarct involving the right parietal and occipital lobes. Other sampled residents also had unreported abnormal BG readings. Resident #2, with orders for Lantus and Humalog sliding-scale insulin, had multiple hyperglycemic readings above the sliding-scale notification thresholds (e.g., 376–478 mg/dL) and several hypoglycemic episodes with BG values between 43–54 mg/dL. On several of these occasions, there was no documentation that Glutose or glucagon was administered, and no evidence that the physician or NP was notified when BG values met either the sliding-scale notification parameters or the facility’s policy thresholds. For at least one hypoglycemic episode (BG 43 mg/dL), medication treatment was documented, but other low readings lacked such documentation. Similar patterns of unreported abnormal BG values and lack of documented hypoglycemia treatment were identified for additional residents reviewed for medication administration, contributing to the finding that the facility failed to ensure appropriate treatment and provider notification for out-of-parameter BG readings. Surveyors determined that the facility’s failure to ensure Resident #1 received care and services to maintain BG levels within a safe range, and to follow policies and orders for provider notification and hypoglycemia management, resulted in Immediate Jeopardy at F684. The Immediate Jeopardy period was identified as beginning on 1/1/2026 and was later removed, but noncompliance at F684 continued at a lower scope and severity for ongoing monitoring of the effectiveness of corrective actions.
Failure to Timely Report Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical and verbal abuse to the state survey agency within the required two-hour timeframe. Facility policy required any partner with direct or indirect knowledge of events that might constitute abuse, neglect, misappropriation of patient property, or exploitation to report immediately, but not later than two hours if the events involved abuse or resulted in serious bodily injury, and not later than 24 hours if they did not. Resident #89, admitted with severe dementia with agitation, muscle weakness, and difficulty walking, required assistance of two staff for ADLs. A Facility Reported Incident form documented that on 01/12/2026 at 12:00 PM, the resident became combative during perineal care and witnesses observed CNA #4 strike and pinch the resident several times, hold the resident by the wrists, make threatening comments, and use inappropriate language. However, this allegation was not submitted to the state reporting agency until 01/14/2026 at 2:57 PM. Witness statements from CNAs #3, #5, and #6 described multiple episodes of rough and aggressive behavior by CNA #4 toward Resident #89 during care on 01/12/2026 and 01/13/2026, including roughly taking the resident’s arms, cursing at the resident, slamming the resident’s wrists onto the chest, making threats, and telling the resident they belonged in a psychiatric ward while pushing the resident’s arms into the chest. The DON stated that on 01/14/2026 these CNAs reported the allegations of abuse from the prior dates, and confirmed that her expectation was that allegations of abuse be reported immediately. The Administrator similarly stated that staff were expected to report allegations of abuse immediately and no later than two hours from when the abuse occurred, and that the facility had two hours to report the allegation to the state reporting agency. He acknowledged that CNAs #3, #5, and #6 did not report the allegations in a timely manner, resulting in the late reporting of the abuse allegation to the state survey agency.
Failure to Implement Fall Intervention After Prior Fall
Penalty
Summary
The facility failed to implement a fall-related care plan intervention for Resident #7 after a fall on 5/15/2025. The resident was admitted with diagnoses including COPD, lack of coordination, and anxiety disorder, and a quarterly MDS assessment indicated a BIMS score of 15, showing the resident was cognitively intact and independent with all aspects of care. After the 5/15/2025 fall, nursing documentation stated the resident was found sitting on the floor after trying to get to the bathroom and slipping, and the incident report identified the root cause as footwear, with a new intervention of nonskid strips to the exiting side of the bed. The comprehensive care plan dated 5/15/2025 included the intervention of nonskid strips to the bedside. However, the facility later failed to have those nonskid strips in place. On 4/12/2026, Resident #7 was again found on the floor beside the bed after hollering for help, and the incident report and nursing note documented the fall. A radiology report from that date showed a left intertrochanteric fracture, and an operative note dated 4/15/2026 documented internal fixation of the left hip. During observations on 4/21/2026, surveyors found no nonskid strips at the bedside, and both the LPN and DON confirmed they were not in place. The DON acknowledged the resident had fallen on 5/15/2025 and that nonskid strips had been the intervention, but they were not present at the time of the later fall. The ADM also confirmed the strips were not in place, and the RD stated they were placed only after the facility was informed on 4/21/2026 that they were missing.
Resident Trust Funds Exceeded Medicaid Asset Limit
Penalty
Summary
The facility failed to maintain resident trust fund balances under the $2,000 Medicaid asset limit for 10 of 111 sampled residents. Review of the American Council on Aging website showed that in 2026, a single Medicaid nursing home applicant in Tennessee must have assets under $2,000. Medical record and trust fund statement reviews showed multiple residents had balances above that limit, including residents with diagnoses such as atrial fibrillation, dementia, depression, dysphagia, anxiety, hemiplegia, heart failure, diabetes, chronic kidney disease, anemia, bipolar disorder, chronic respiratory failure, Parkinson’s disease, traumatic subdural hemorrhage, malnutrition, and hypertension. Resident trust fund statements dated 4/22/2026 showed balances of $4,945.96 for Resident #11, $7,764.26 for Resident #16, $3,324.09 for Resident #38, $2,950.01 for Resident #86, $5,350.97 for Resident #92, $3,874.46 for Resident #101, $3,931.97 for Resident #110, $2,769.53 for Resident #119, $5,911.60 for Resident #128, and $9,020.33 for Resident #177, all above the $2,000 limit. During interview, the BOM stated the resident trust account limit was $2,000.00, and the Administrator also stated resident trust accounts should be under $2,000.00.
Unsecured and Unlabeled Medications Found at Bedside and in Medication Cart
Penalty
Summary
Medications and biologicals were not properly stored in accordance with facility policy and accepted professional principles when medications were left unattended and unlabeled at a resident’s bedside and when prepared medications were left unsecured and unlabeled in a medication cart. The facility policy stated medications and biologicals are to be stored safely, securely, and properly, with access limited to authorized staff, and that all medications dispensed by the pharmacy are to be stored in the container with the pharmacy label. The self-administration policy required a physician order and interdisciplinary assessment before a resident could self-administer medications, along with a quarterly skill assessment as needed. Resident #41 was admitted with diagnoses including Autistic Disorder, Gilbert Syndrome, Delusional Disorders, Hypertension, Edema, Protein-Calorie Malnutrition, and Peripheral Vascular Disease. The physician ordered multiple 9:00 AM oral medications, but there was no physician order for self-administration and the resident was not assessed or care planned for self-administration, despite a BIMS score of 13 indicating cognitive intactness. During observation, 3 white tablets, 2 orange tablets, 2 light blue and yellow capsules, and 1 white half tablet were found in a clear cup on the resident’s nightstand unattended and unlabeled, and an LPN identified them as the resident’s scheduled medications. In a separate observation, a medication cart contained unsecured and unlabeled medication cups with tablets and a capsule in the drawers, and the DON stated medications that were prepared and unable to be administered should be wasted and not stored in the med cart.
Failure to Maintain Bed Safety and Hazard-Free Environment Resulting in Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to implement and follow care-planned safety interventions for a resident with significant cognitive and physical impairments. The resident had diagnoses including Alzheimer’s disease, dementia, psychotic disorder with delusions, anxiety, obsessive-compulsive behavior, peripheral vascular disease, convulsions/seizure disorder, and a history of repeated falls. The care plan identified the resident as at risk for falls related to unstable balance, decreased safety awareness, impaired decision-making skills, and lack of coordination, and included interventions such as keeping the bed in the low position with brakes locked and, later, a fall mat to the left side of the bed. A fall risk assessment documented the resident as high risk for falls, and prior falls from bed had resulted in at least one laceration requiring sutures and antibiotic treatment. Despite these known risks and documented interventions, there was no evidence that the care plan was revised to add further bed-related safety interventions after repeated falls from bed. On the night of the fatal incident, the resident, who was dependent on staff for transfers, bed positioning, and turning, was last seen by a CNA around 3:40–3:45 a.m., when incontinence care was provided and the resident was reported to be “alive and fine in bed.” The same CNA later stated that at that time the bed was typically at about “waist high,” rather than in the lowest position. Around 4:50–4:55 a.m., the CNA found the resident lying supine on the floor, partially underneath the bed, with the bed in the lowest position and the corded bed control stretched across the resident’s neck area and pinned under her back near the left shoulder. Witness statements from CNAs and nursing staff, as well as EMS and police narratives, consistently described the resident’s head and torso as being under the bed frame, with visible compression marks on the chest, abdomen, and face consistent with the bed frame and piston, and a chunk of hair lodged in a bolt on the lower bed frame. Staff reported that the bed had to be raised using the remote, which was under the resident, before the resident could be pulled out from under the bed. Investigative interviews and external reports identified additional environmental and supervision-related hazards. A detective observed that a fall alert system was attached to the bed rail but was not plugged in or set up to provide any alert if the resident attempted to get out of bed or fell. The detective also found the call light tucked behind the nightstand, out of the resident’s reach, although it functioned when tested. Multiple staff, including CNAs, nurses, the OT, and the physician, confirmed that the resident could not walk, could not turn herself in bed, was a two-person assist, and was totally dependent on staff for bed position and care. Several staff stated they had never seen a fall mat at the bedside, despite the care plan calling for one, and confirmed that the bed was supposed to be kept in the lowest position due to the resident’s fall risk. The DON and previous administrator acknowledged that the resident was found under the bed with marks consistent with the bed frame and that the bed should have been all the way down to the floor, while also indicating that the incident was considered an accident and that no report had been made to the state survey agency. The surveyors concluded that the facility failed to ensure that care-planned safety interventions (bed in low position, fall mat) were implemented and that the environment (including bed equipment, fall alarm, and call light accessibility) was free of accident hazards, resulting in a serious injury and death for this resident. The facility’s own policy on “Safety and Supervision of Resident” stated that the environment should be made as free from accident hazards as possible and that interventions to reduce accident risks included communicating specific interventions to all relevant staff, providing training, and ensuring interventions are implemented. However, the record showed that after multiple falls, including one with injury, the care plan was not updated with additional bed-related safety measures beyond a single fall mat, and there was no documentation that the existing interventions (bed in low position, brakes locked, fall mat, call light within reach) were consistently implemented. Staff interviews revealed discrepancies about who initiated CPR and who raised the bed, but they consistently indicated that the resident was dependent, that the bed was expected to be in the lowest position, and that the resident’s ability to use the call light or bed remote was limited or absent. External responders (EMS and police) documented that staff did not know how long the resident had been pinned, that the bed’s corded control was found under the resident, and that the fall alert system and call light were not positioned to protect or assist the resident. These combined findings formed the basis for the cited deficiency at F689 for failure to prevent accidents and maintain an environment free of accident hazards.
Failure to Consistently Implement Safety Measures After Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from physical abuse by another resident on two separate occasions. One resident, admitted with chronic kidney disease, essential hypertension, and type 2 diabetes mellitus, had a quarterly MDS BIMS score of 15, indicating intact cognition. Another resident, admitted with aphasia, cognitive communication deficit, chronic kidney disease, and non-Hodgkin lymphoma, had a quarterly MDS BIMS score of 3, indicating severe cognitive impairment. On one date, nursing documentation showed staff were called to the room and observed a CNA removing the cognitively impaired resident from the cognitively intact resident’s room after the latter reported being hit three times on the left arm. A same-day skin assessment documented slight redness above the antecubital area. Following this first incident, the cognitively intact resident’s care plan was revised to include a stop sign on the door as an intervention. Despite this, a second incident occurred when a nurse at the nurse’s station heard yelling in the hall and then observed the cognitively impaired resident exiting the same resident’s room. When questioned, the cognitively intact resident reported that she had asked the other resident to leave and was then hit. The facility’s investigation documented that the residents were separated and that a skin assessment revealed redness to the left upper breast and left index finger knuckle, with no open areas or swelling and the resident denying pain. A later skin assessment the same evening documented no areas of concern. Surveyor observations and interviews showed that the stop sign intervention was not consistently implemented, contributing to the recurrence of resident-to-resident physical contact. An employee warning form documented that a staff member failed to reattach the stop sign across the doorway after returning the resident from an appointment. During surveyor observation, the stop sign was again not in place outside the resident’s room, and no staff were in sight while the resident sat on the side of the bed. The resident reported that the other resident had come into her room on two occasions and struck her and stated that staff did not keep the stop sign up much. An LPN acknowledged that the stop sign was supposed to be in place and admitted forgetting to put it back up after exiting the room. The DON confirmed that physical contact occurred on both dates when the cognitively impaired resident struck the cognitively intact resident, although neither resident sustained injuries.
Failure to Implement Care Plan Intervention for Door Stop Sign
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan intervention for one resident as required by facility policy. The facility’s care plan policy, revised March 2022, states that comprehensive care plans must include measurable objectives and interventions derived from a thorough analysis of information to meet residents’ physical, psychosocial, and functional needs. Resident #15 was admitted with chronic kidney disease, essential hypertension, and type 2 diabetes mellitus, and a quarterly MDS showed the resident was cognitively intact with a BIMS score of 15. The resident’s comprehensive care plan, revised 4/21/2025, included an intervention for a stop sign to be placed on the resident’s door, with staff to assist as needed to keep the stop sign in place. On 4/14/2026 at 8:24 AM, surveyors observed that the stop sign outside Resident #15’s room was not in place, and no staff were in sight of the room while the resident was sitting on the side of the bed. During an interview at 8:25 AM, the resident stated that staff did not keep the stop sign up much anymore. At 8:27 AM, an LPN acknowledged that the stop sign was supposed to be in place and admitted it was their fault, explaining they had forgotten to put the stop sign back up after exiting the resident’s room. At 8:40 AM, the DON, upon interview and medical record review, confirmed that the care plan intervention for the stop sign on the resident’s door had not been followed and stated she expected the stop sign to be in place for this resident.
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