Fairpark Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Maryville, Tennessee.
- Location
- 307 N Fifth St Box 5477, Maryville, Tennessee 37801
- CMS Provider Number
- 445286
- Inspections on file
- 17
- Latest survey
- July 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Fairpark Health And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that an employee's personal food items were stored in the kitchen cooler with residents' food, and multiple boxes of frozen vegetables in the freezer were not properly sealed, resulting in exposure to air and visible discoloration. The Dietary Manager confirmed these practices did not follow facility policy or professional standards.
A resident with multiple medical conditions was given her roommate's medications after an LPN failed to properly verify her identity and medication details, despite the resident questioning the number of pills. The error was discovered after administration, and the resident experienced no adverse effects.
Sensitive health information was left visible and unattended on a medication cart, including data displayed on a computer screen and a written shift-to-shift communication sheet listing residents' names and medical conditions. An LPN failed to secure this information before leaving the cart, and the ADON confirmed the breach of confidentiality.
A resident with a history of Bipolar Disorder, Depression, and Anxiety, and a documented PASRR Level II outcome for serious mental illness, was not accurately coded for PASRR Level II status on a significant change MDS assessment. The error was confirmed by the RN MDS Coordinator during review, despite facility policy requiring accurate and comprehensive assessments.
Staff failed to perform hand hygiene after serving meal trays to three residents, did not wear required PPE when delivering a meal tray to a resident on contact isolation, and did not offer hand hygiene assistance to a dependent resident before a meal. These actions were confirmed by staff interviews and were not in accordance with facility infection control policies.
The facility failed to maintain a clean and homelike environment in one hallway and five resident rooms. Observations revealed dirty baseboards, scuffed floors, and unsanitary conditions in the rooms and hallway. The Administrator and Environmental Service Manager confirmed these findings.
The facility failed to complete a significant change assessment for a resident with multiple diagnoses who was ordered hospice care. Despite the hospice order, the required assessment was not completed within 14 days, and the resident's MDS assessment did not reflect hospice services. This was confirmed by an MDS RN.
The facility failed to accurately complete MDS assessments for three residents, leading to deficiencies in documenting anticoagulant use, hospice care, and physical restraints. One resident was incorrectly documented as receiving an anticoagulant, another was not coded for hospice care despite having an order, and a third was inaccurately documented as using physical restraints.
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, admitted with multiple diagnoses including Right Hip Fracture and Dementia, did not have a baseline care plan until 96 hours after admission. This was confirmed by the Area Nurse Director.
The facility failed to follow a physician's order for two residents who were prescribed double protein portions at all meals to promote wound healing. Due to a glitch in a new computer system, the dietary orders were not transferred correctly, leading to the residents not receiving the prescribed portions. Despite being on other protein supplements, the deficiency was confirmed through interviews and observations.
The facility failed to secure hazardous chemicals in a resident bathroom, leaving a bottle of bleach and another of odor control accessible to three residents. Despite the residents' assurances that they would not ingest the chemicals, the unsecured presence of these substances violated the facility's safety policies.
The facility failed to provide trauma-informed care for a resident with PTSD, as staff were unaware of the diagnosis and potential triggers. The resident's care plan did not include identified problems or triggers related to PTSD, despite the facility's policy requiring such measures.
The facility failed to maintain dryer lint screens in the laundry room, resulting in a thick layer of lint build-up on the screens and accumulation on the floor. The Lint Trap Clean Out Log was not completed, and the Environmental Services Manager could not confirm when the screens were last cleaned.
Improper Storage of Personal and Frozen Food Items in Kitchen
Penalty
Summary
The facility failed to comply with its own food storage policy and professional standards by allowing an employee's personal food items, specifically a purple lunch box and a carbonated beverage, to be stored in the kitchen reach-in cooler alongside residents' food items. This was confirmed during an observation and interview with the Dietary Manager, who acknowledged that these personal items belonged to a dietary employee and should not have been stored with food intended for residents. Additionally, the facility did not ensure that frozen food items were properly sealed and stored in the reach-in freezer. Observations revealed that boxes of frozen peas, California blend vegetables, and sliced carrots were not sealed properly, resulting in exposure to air and visible discoloration on the food surfaces. The Dietary Manager confirmed that these items were not stored appropriately, as required by facility policy and FDA Food Code guidelines.
Medication Error Due to Failure to Follow Identification Procedures
Penalty
Summary
A medication error occurred when a resident, who was cognitively intact and had diagnoses including cerebral infarction, morbid obesity, and chronic pain syndrome, was administered her roommate's medications instead of her own. The error took place when an LPN prepared the roommate's medications, entered the resident's room, and, after verbalizing the roommate's name, gave the medication cup to the resident who responded. The resident questioned the number of pills, as it was more than she typically received, but ultimately took the medication. The LPN later realized the mistake after verifying the medications and confirmed that the wrong medications had been administered. Facility documentation and interviews confirmed that the medications given in error included Doxepin, Tylenol, Famotidine, Gabapentin, and Senna. The resident did not experience any adverse reactions following the incident. The error was identified and reported immediately to the appropriate staff, including the nurse practitioner, administrator, and director of nursing. The facility's policy required verification of resident identity and medication details prior to administration, but these procedures were not followed, resulting in the medication error.
Failure to Secure Residents' Health Information on Medication Cart
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records as required by its own policy. During an observation, sensitive health information was found displayed on the computer screen of a medication cart located in the 100 hall. Additionally, a written shift-to-shift communication sheet containing residents' names and various medical conditions was stored on top of the same medication cart. Both the computer screen and the communication sheet were left unattended and visible, making the information accessible to unauthorized individuals. The Licensed Practical Nurse (LPN) assigned to the cart left the area without securing or covering the residents' personal and confidential medical information. Upon returning briefly to the cart, the LPN again failed to ensure the information was protected before leaving the cart unattended. The Assistant Director of Nursing (ADON) confirmed during an interview that the residents' sensitive health information was not secured and acknowledged that it was available for public viewing.
Inaccurate MDS Assessment for Resident with PASRR Level II Status
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident who was reviewed for MDS assessments. Specifically, a resident with a documented PASRR Level II outcome for serious mental illness, including diagnoses of Bipolar Disorder, Depression, and Anxiety, was not accurately coded for their PASRR Level II status on a significant change MDS assessment. The PASRR Level II screening had been completed prior to admission and indicated the need for certain care and services related to serious mental illness. Despite the resident's medical record and psychiatric notes confirming ongoing diagnoses of Bipolar Disorder and Anxiety, the significant change MDS assessment did not reflect the resident's PASRR Level II status. During a review and interview, the RN MDS Coordinator acknowledged the inaccuracy in the assessment. The facility's policy and federal regulations require accurate and comprehensive assessments using the RAI process, but this was not followed in this instance.
Failure to Perform Hand Hygiene and Use PPE During Meal Service
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies during meal tray distribution, as evidenced by multiple staff omissions in hand hygiene and use of personal protective equipment (PPE). Specifically, the Assistant Director of Nursing (ADON) delivered and set up lunch meal trays for three residents without performing hand hygiene after each interaction, despite facility policy requiring hand hygiene between resident contacts. These residents had varying degrees of cognitive and physical impairment, with some requiring setup or clean-up assistance with eating and personal hygiene. Additionally, the ADON failed to don appropriate PPE when delivering a meal tray to a resident who was on contact isolation, contrary to the facility's transmission-based precautions policy. The resident in question required setup assistance with eating and partial to moderate assistance with personal hygiene. The ADON acknowledged not wearing the required PPE before entering the room, despite being aware of the resident's isolation status. Furthermore, a Licensed Practical Nurse (LPN) did not offer hand hygiene assistance to a resident who was dependent on staff for personal hygiene prior to serving the lunch meal. This omission was confirmed by the LPN during an interview. Both the Infection Preventionist and the Director of Nursing confirmed that staff are expected to perform hand hygiene before and after delivering meal trays, don appropriate PPE for residents on contact isolation, and offer hand hygiene assistance to all residents prior to meals.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in one of its hallways and in five resident rooms. Observations revealed that Resident #37's bathroom had a visibly dirty black mat under the sink, a dusty and dirty fan base, chipped paint on the sink doors, and dirty baseboards. Resident #418's room had dark scuff marks on the floor, broken baseboards, and visible dirt and debris behind the entrance door. Resident #1's room also had dark scuff marks, broken baseboards, and visible dirt and debris behind the entrance door. Resident #39's room had visible dirt, dust, and debris behind the entrance door, while Resident #15's room had a brown substance on the floor, loose particles behind the headboard, and dirty debris near the chest of drawers. Additionally, the 200-hallway had dirty baseboards, scuffed floors, and dirty entrance doors to all resident rooms. The housekeeping cart in the hallway was also found to be dirty and unsanitary, with crusty debris on the dustpan, a dried substance on the locked cabinet, and loose particles and a brown substance on the black tray at the bottom of the cart. During interviews, the Administrator and Environmental Service Manager confirmed the observations and acknowledged that the 200-hallway and the rooms of Residents #37, #418, #1, #39, and #15 were not maintained in a clean, sanitary, and homelike environment. The facility's policy on routine cleaning and disinfection, which aims to ensure a safe and sanitary environment, was not adhered to, leading to the observed deficiencies.
Failure to Complete Significant Change Assessment
Penalty
Summary
The facility failed to complete a significant change assessment for a resident who had a significant change in condition. The resident, who had diagnoses including Diabetes, End Stage Renal Disease, Hypertension, and Anemia, was admitted to the facility and later had hospice care ordered. Despite the order for hospice services being effective on 8/21/2023, the facility did not complete a significant change assessment within the required 14 days. An annual Minimum Data Set (MDS) assessment showed the resident had moderate cognitive impairment but did not indicate the resident was receiving hospice services. This deficiency was confirmed during an interview with an MDS Registered Nurse who acknowledged that the significant change assessment had not been completed within the required timeframe.
Inaccurate MDS Assessments for Anticoagulant Use, Hospice Care, and Restraints
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the documentation of anticoagulant use, hospice care, and physical restraints. Resident #39, who was admitted with multiple diagnoses including Diabetes and End Stage Renal Disease, was inaccurately documented as receiving an anticoagulant when the medication prescribed was actually an antiplatelet (Clopidogrel). This error was confirmed by MDS RN #1 during an interview. Resident #36, who had moderate cognitive impairment and was receiving hospice care, was not coded correctly in the MDS assessments to reflect the hospice services, despite having an order for hospice care effective from 8/21/2023. This inaccuracy was also confirmed by MDS RN #1 during an interview. Resident #33, admitted with diagnoses including Cerebral Infarction and Functional Quadriplegia, was inaccurately documented as using physical restraints in the MDS assessment. Observations over several days showed that the resident did not have any restraints in use, which was confirmed by MDS RN #1. These inaccuracies in the MDS assessments indicate a failure by the facility to ensure accurate and complete documentation, which is essential for proper resident care and regulatory compliance.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, who was admitted with diagnoses including Right Hip Fracture, Dementia, Dislocation of Right Hip, Depression, and Adult Failure to Thrive, did not have a baseline care plan developed until 96 hours after admission. This was confirmed during an interview with the Area Nurse Director, who acknowledged the failure to meet the 48-hour requirement for developing a baseline care plan.
Failure to Follow Physician's Orders for Double Protein Portions
Penalty
Summary
The facility failed to follow a physician's order for two residents who were prescribed double protein portions at all meals to promote wound healing. Resident #61, who had diagnoses including Hypertension, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and a Pressure Ulcer to the Buttocks, was not receiving the prescribed double protein portions. This was confirmed through interviews with the resident and observations of meal portions. Similarly, Resident #418, who had diagnoses including Cellulitis of the Left Lower Limb, Type 2 Diabetes with Hypoglycemia, Hypertension, and Peripheral Vascular Disease, also did not receive the prescribed double protein portions. Both residents' dietary orders were not transferred correctly to a new computer system implemented by the facility, leading to inaccurate dietary meal tickets. Interviews with the Dietary Aide, Dietary Manager, Regional Dietary Manager, Area Nurse Director, Registered Dietician, and Nurse Practitioner confirmed that the dietary orders for double protein portions were not followed due to a glitch in the new computer system. Despite the residents being on other protein supplements, the failure to provide double protein portions as ordered was identified. The residents' wounds were reported to be stable and had not deteriorated, but the deficiency in following the physician's orders was evident.
Unsecured Chemicals in Resident Bathroom
Penalty
Summary
The facility failed to ensure that chemicals were secured in the bathroom shared by three residents, leading to a potential safety hazard. The facility's policy mandates that chemicals should be locked at all times, but during an observation, a 32-ounce bottle labeled as glass cleaner but containing bleach, and another bottle labeled as odor control, were found unsecured on the sink. Both bottles were confirmed to contain hazardous chemicals, which were accessible to the residents. This was confirmed by both an LPN and the Environmental Service Manager, who immediately removed the bottles upon discovery. Resident #37, who has diagnoses including Type 2 Diabetes and Congestive Heart Failure, was found lying in bed during the observation. Resident #8, diagnosed with Adult Failure to Thrive and Repeated Falls, was observed walking independently with a walker. Resident #41, who has Vascular Dementia and moderate cognitive impairment, was seen independently using a wheelchair. Despite their varying levels of mobility and cognitive function, the unsecured chemicals posed a risk to all three residents. Interviews with staff and residents revealed that the housekeeper had left the chemicals unsecured when she was called away. The residents, when asked, indicated they would not ingest the chemicals if they saw the labels, but the unsecured presence of these hazardous substances still violated the facility's safety policies. Observations over several days confirmed that there were no wandering residents in the hallway, but the failure to secure the chemicals still represented a significant oversight in maintaining a safe environment.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for Resident #54, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, a fracture of the right femur, muscle weakness, and Post Traumatic Stress Disorder (PTSD). Despite the facility's policy requiring screening for trauma history and accounting for residents' experiences and preferences to mitigate triggers, Resident #54's comprehensive care plan did not identify problems or triggers related to PTSD. The resident, who had a BIMS score indicating cognitive intactness, reported a history of PTSD due to childhood abuse but stated that her current medication regimen kept her stable. However, the facility did not inquire about her PTSD or potential triggers upon admission, and no triggered episodes occurred during her stay at the facility. Interviews with various staff members, including CNAs, an LPN, and a Psychiatric Nurse Practitioner, revealed that none were aware of Resident #54's PTSD diagnosis or potential triggers for behavioral episodes. The Social Services Director confirmed that although a trauma-informed screening was completed, it did not include specific triggers, nor were they added to the resident's care plan. The facility's Administrator, Administrator in Training, and Area Nurse Director acknowledged that the facility's trauma-informed care policy had not been followed, leading to the deficiency in providing appropriate care for Resident #54.
Failure to Maintain Dryer Lint Screens
Penalty
Summary
The facility failed to maintain mechanical equipment in a safe operating condition, specifically in the laundry room. During an observation, both dryers were found with a thick layer of lint build-up on the screens and lint accumulation on the floor beneath them. The facility's policy requires lint screens to be cleaned and brushed every hour and after every load, but the Lint Trap Clean Out Log had not been completed for the observed date. The Environmental Services Manager confirmed the lint build-up and the lack of documentation for the cleaning of the dryer screens, noting that the responsible person had left for the day and she could not confirm when the screens were last cleaned.
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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