Humphreys County Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Waverly, Tennessee.
- Location
- 104 Fort Hill Road, Waverly, Tennessee 37185
- CMS Provider Number
- 445489
- Inspections on file
- 16
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Humphreys County Care And Rehabilitation during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and complex medical conditions experienced significant weight loss, but recommended nutritional interventions from the RD were not communicated to or implemented by clinical staff. The DON and NP were unaware of the recommendations, and the facility failed to ensure timely follow-up, resulting in actual harm due to unmet nutritional needs.
The facility did not maintain an adequate emergency water supply as required by its policy, with only a 3-day supply of bottled water for drinking and cooking and two out of four hot water heaters not operational. The Administrator confirmed there was not enough water to meet the needs of all residents and staff for a 3-day emergency period.
The facility did not maintain a qualified Dietary Manager as required, leaving the kitchen without appropriate supervision after the previous DM resigned. Staff interviews revealed confusion about who was in charge, with a CNA and a cook temporarily filling supervisory roles despite lacking the necessary credentials. The Registered Dietician only visited twice monthly and was not managing the kitchen, resulting in noncompliance with staffing regulations.
Staff failed to maintain resident dignity during dining by addressing a resident with inappropriate endearments and serving meals in the hallway to three residents without care-planned preferences. The affected residents had significant cognitive impairments and required assistance, and staff interviews confirmed these actions were not in line with facility policy.
The facility did not provide written information on how to formulate an advance directive to several residents, as required by policy. Medical record reviews and staff interviews confirmed that neither residents nor their responsible parties received the necessary documentation, affecting individuals with a range of cognitive and medical conditions.
A resident with moderate cognitive impairment reported missing money from her nightstand on multiple occasions, but the allegation was not reported to State or local agencies as required by facility policy. Staff confusion and lack of communication led to the failure to follow mandated reporting procedures for suspected misappropriation of resident property.
A resident with moderate cognitive impairment reported missing money from her nightstand. The facility's investigation was limited to interviews with the resident and her responsible party, and an observation of money in the room, but did not include staff interviews or comprehensive documentation, resulting in a failure to thoroughly investigate the misappropriation allegation.
Two residents did not have comprehensive care plans reflecting their current needs and physician orders. One resident with severe cognitive impairment and multiple psychotropic and opioid medications lacked care plan documentation for medication use and monitoring. Another resident with hemiplegia and contractures did not have care plan interventions for passive range of motion or hand splint application, despite physician orders requiring these treatments.
The facility did not timely update care plans for two residents after significant changes in their conditions or treatments. One resident's care plan was not revised promptly after a fall, and another resident's care plan was not updated to reflect discontinued diuretic and psychotropic medications, despite these changes being known to staff.
Unsecured disposable razors and cleaning chemicals were found in the rooms of several residents, including those with cognitive impairment and physical dependency. Despite facility policies requiring immediate disposal of sharps and removal of hazardous items, these items were left unattended on bathroom sinks. RNs and the DON confirmed that such items should not be left unsecured.
Medications were found unsecured in the bathrooms of two residents who required staff assistance, and a medication cart was left unlocked and unattended during administration. Additionally, temperature logs for medication refrigerators on two halls were incomplete, with multiple dates missing required entries. The DON confirmed these practices did not follow facility policy.
Staff failed to perform hand hygiene between assisting multiple residents during meal service, including handling food and straws with bare hands, and did not properly store soiled linens, leaving them on the floor in a resident's room. These actions were not in accordance with facility infection control policies, as confirmed by staff and the DON.
The facility failed to protect food from contamination due to improper hand hygiene and handling by staff, including CNAs and the Admissions Coordinator. Observations showed staff touching food with bare hands and not performing hand hygiene. Additionally, ice machines were found with stains and biofilm, indicating poor maintenance. An opened, undated ice cream container was also found in the resident refrigerator, lacking proper labeling.
The facility did not provide a private space for the Resident Council Meeting, which was held in an open and noisy Activity Room. The meeting was interrupted multiple times by staff and visitors, and the DON and Activities Director were unaware of the need for privacy, leading to a failure in honoring residents' rights to organize without interference.
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in care planning. One resident was not care planned for monitoring the effects of medications, while another was not care planned for the management of an indwelling catheter. These omissions were confirmed by the MDS Coordinator during interviews.
A facility failed to update a care plan for a resident after an unwitnessed fall. Despite a policy requiring care plan revisions following status changes, the resident's care plan was not updated with appropriate interventions after the incident. The resident, who was at risk for falls and required substantial assistance with ADLs, did not have their care plan revised post-fall, as confirmed by the ADON.
A resident with cognitive impairment was found accessing potentially hazardous items at a nursing station, including scissors and aerosol sprays. Staff interviews revealed that the resident was kept at the nursing station to prevent falls, but inadequate supervision and improper storage of chemicals led to the exposure. The DON and RN confirmed that such items should not be stored unattended.
Two residents in an LTC facility received improper indwelling urinary catheter care. A CNA left one resident uncovered and used the same washcloth for cleaning both the scrotum and catheter. Another CNA failed to perform hand hygiene between glove changes and did not clean the shaft of the penis during catheter care. The DON confirmed these actions were against facility policy.
A facility failed to maintain consistent communication with a dialysis center for a resident requiring dialysis, as evidenced by incomplete or missing communication forms. The facility's policy requires collaboration with the dialysis center to meet the resident's needs, but interviews revealed lapses in documentation and communication. The ADON acknowledged the need for accurate monitoring of forms, while the RN Charge Nurse noted inconsistent receipt of forms from the facility.
A resident with severe cognitive impairment and hypertension was administered Metoprolol and Amlodipine despite having a diastolic blood pressure below the physician's specified threshold. The facility's policy requires holding medications if vital signs fall outside prescribed parameters, but this was not followed, leading to a significant medication error.
Two residents with cognitive impairments were found with unsecured medications in their rooms and at the nursing station. A resident had mentholated ointment in her room despite being assessed as unable to self-administer medications. Another resident accessed a drawer with ointments at the nursing station, which should not have been unattended. The DON confirmed these storage lapses.
The facility failed to implement enhanced barrier precautions for residents with wounds and indwelling medical devices, as required by their policy. Observations showed that staff did not use PPE during care activities for residents with pressure ulcers, urinary catheters, and gastrostomy tubes. Interviews revealed a lack of awareness and implementation of these precautions, despite initial education and plans to implement them.
Failure to Implement Dietician Recommendations for Residents with Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for two residents who experienced significant weight loss. Policy review showed that the facility was required to monitor weight changes and implement, monitor, and modify interventions as needed. For both residents, the Registered Dietician identified significant weight loss and recommended the addition of house supplements twice daily. However, these recommendations were not communicated to or implemented by the appropriate clinical staff. The Nurse Practitioner confirmed she was not made aware of the recommendations, and the DON acknowledged that the process for reviewing and acting on dietary recommendations was not followed due to staff absence and lack of follow-up. Both residents involved had complex medical histories, including severe cognitive impairment, dementia, and conditions such as aphasia, Parkinson's Disease, and adult failure to thrive. Despite documented weight loss—nearly 10% for one resident and over 5% for the other—there was no evidence that the recommended nutritional interventions were ordered or provided. The failure to implement these interventions resulted in actual harm to the residents, as the facility did not ensure their nutritional needs were met according to policy and clinical assessment.
Insufficient Emergency Water Supply Maintained
Penalty
Summary
The facility failed to ensure a sufficient emergency water supply was available for all 76 residents, as required by its own policy. The policy specified the amount of water needed for drinking, handwashing, cooking, toilet flushing, and miscellaneous uses, based on the number of residents and staff. During observation and interviews, it was found that only a 3-day supply of bottled water for drinking and cooking was maintained by the Dietary Manager. Additionally, in the boiler room, two out of four hot water heaters, each with a capacity of 116 gallons, were not operational, with one having its front panel missing and both turned off. The Business Office Manager confirmed the limited operational capacity, and the Administrator acknowledged that the facility did not have enough water to maintain a 3-day emergency supply for the average number of 52 employees and all residents.
Failure to Maintain Qualified Dietary Management Staff
Penalty
Summary
The facility failed to employ sufficient and qualified dietary staff to manage the food and nutrition service for all 76 residents. The job description for the Director of Food Services requires a graduate of an accredited dietetic program, at least five years of supervisory experience in a medical facility, and registration as a Food Service Director in the state. However, interviews and observations revealed that the facility did not have a Dietary Manager (DM) at the time of the survey, as the previous DM had quit approximately two weeks prior. Staff interviews indicated confusion and lack of clarity regarding who was supervising the kitchen, with a Certified Nursing Assistant (CNA) temporarily called in to fill the DM role, but also being assigned to CNA duties on the resident care floor. Further interviews with dietary staff, the Registered Dietician (RD), and the Administrator confirmed that the kitchen was being supervised by a cook, who did not hold the required qualifications for the DM position. The RD only visited the facility twice a month and was not managing the kitchen. The Administrator acknowledged that there was no current DM, and the cook was acting as the supervisor. This lack of qualified dietary management resulted in the facility not meeting regulatory requirements for food and nutrition service staffing.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to maintain resident dignity and respect during dining, as evidenced by staff not using courtesy titles and serving meals in the hallway without care planning for such preferences. Specifically, a registered nurse addressed a moderately cognitively impaired resident using terms such as "honey," "baby," and "babydoll" during meal service, contrary to facility policy which requires the use of courtesy titles and prohibits the use of endearments. Additionally, certified nursing assistants served meals to three severely cognitively impaired residents in the hallway while they were seated in Geri-chairs or Broda chairs, despite none of these residents having care plans indicating a preference for hallway dining. Medical record reviews confirmed that the affected residents had significant cognitive impairments and required staff assistance for activities of daily living, including eating. Observations documented that meals were provided and assistance was given in the hallway rather than in designated dining areas or according to resident preference. Interviews with facility staff, including the RN, MDS Coordinator, and DON, confirmed that serving meals in the hallway without care planning and failing to use appropriate forms of address were not in accordance with facility policy or resident rights.
Failure to Provide Written Information on Advance Directives
Penalty
Summary
The facility failed to provide written information on how to formulate an advance directive to 9 out of 24 sampled residents. Policy review indicated that the Admissions Director or designee is responsible for providing this information prior to or upon admission. However, medical record reviews for multiple residents with various diagnoses, including chronic illnesses and cognitive impairments, showed no documentation that either the residents or their responsible parties received the required written information regarding advance directives. Interviews with facility staff confirmed the deficiency. The Administrator acknowledged the facility's responsibility to provide written documentation on advance directives, and the Social Services Director stated that there was no current process in place to ensure residents received this information. The lack of documentation and process affected residents with a range of cognitive abilities, from cognitively intact to severely impaired, and included those with significant medical conditions such as COPD, heart failure, diabetes, and cancer.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that allegations of misappropriation of resident property were reported in accordance with its own policy and regulatory requirements. Specifically, a resident with moderate cognitive impairment reported missing money from the top drawer of her nightstand, both in her current and previous rooms. The resident was unable to specify the exact amount or date the money went missing, but stated it was mostly loose one-dollar bills. The allegation was brought to the attention of the Administrator, who was also the Abuse Coordinator, but there was confusion among staff regarding who was handling the report, and the Social Services Director was not aware of the specific allegation. Despite the facility's policy requiring immediate reporting of any misappropriation of resident property to the State Regulatory Agency within 24 hours, the allegation was not reported to State and local agencies. Interviews with the resident's nephew confirmed that the resident had reported missing money on multiple occasions, but he had not informed staff. The Administrator and Social Services Director demonstrated a lack of communication and follow-through, resulting in the failure to report the incident as required.
Failure to Conduct Thorough Investigation of Misappropriation Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of misappropriation of property involving a resident who reported missing money from the top drawer of her nightstand. The resident, who was moderately cognitively impaired with a BIMS score of 11 and had diagnoses including Ulcerative Colitis, Atrial Fibrillation, and Urinary Tract Infection, was unable to specify the exact amount or date the money went missing. The allegation was reported to the Administrator, and a grievance form was completed noting the missing money, with the resident's nephew estimating the amount at no more than $6.00 over the past month. The facility's investigation included an interview with the resident, a telephone interview with the responsible party, and an observation of $6.00 hidden in a tissue box on the resident's nightstand. However, the investigation did not include interviews with staff or other residents who might have had knowledge of the incident, nor did it provide thorough documentation of all investigative steps or a comprehensive investigation summary. The Administrator confirmed that a thorough investigation should have included these elements to determine the root cause and resolution of the allegation.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by its own policy. For one resident with severe dementia, depression, and anxiety, the care plan did not address the use of multiple psychotropic and opioid medications, despite medical records showing active orders for antipsychotic, antidepressant, antianxiety, anticonvulsant, and opioid drugs. The resident's care plan lacked documentation on monitoring for side effects or interventions related to these medications, even though specific monitoring instructions were present in the physician's orders. The MDS Coordinator confirmed that the care plan should have included these elements. For another resident with hemiplegia, contractures, and joint derangement, the care plan did not include interventions for passive range of motion (PROM) or the application of hand splints, despite physician orders specifying their use for contracture management. The resident's medical record indicated limited range of motion and the need for both left and right hand splints, but these interventions were not reflected in the care plan. The MDS Coordinator acknowledged that the care plan should have addressed the current use of hand splints and PROM.
Failure to Timely Update Care Plans After Significant Changes
Penalty
Summary
The facility failed to update or revise care plans for two residents following significant changes in their conditions or treatments. For one resident with a history of bipolar disorder, lower back pain, and vertebral fractures, the care plan was not updated in a timely manner after a fall incident. The fall occurred on 8/8/2025, but the care plan was not revised to include new interventions until 9/3/2025. The MDS Coordinator confirmed that interventions should have been added the next working day, but this did not occur. For another resident with anxiety, delusions, depression, and dementia, the care plan continued to include interventions related to diuretic and psychotropic medications even after these medications had been discontinued as of 7/16/2025. The care plan was not revised to reflect this significant change in the resident's medication regimen. The MDS Coordinator confirmed that the care plan should have been updated to reflect the discontinuation of these medications.
Unsecured Sharps and Chemicals Found in Resident Rooms
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by allowing unsecured sharps and cleaning chemicals to be present in the rooms of five sampled residents. Policy review indicated that contaminated sharps should be immediately discarded into designated containers, and items posing risks to residents' health and safety should be confiscated if found in plain view. Despite these policies, observations revealed that disposable razors and cleaning chemicals were left unsecured in resident bathrooms. Registered nurses confirmed during interviews that these items should not have been left unattended or unsecured in resident rooms. The residents involved had varying degrees of cognitive impairment and physical dependency, including diagnoses such as dementia, depression, hypertension, heart failure, and respiratory conditions. Some residents required moderate to total assistance with activities of daily living. The unsecured items included disposable razors, aerosol air freshener, disinfectant spray, and surface cleaner, all found on or under bathroom sinks. The Director of Nursing confirmed that these items should not have been left unsecure and unattended in residents' rooms.
Medication Storage and Security Deficiencies
Penalty
Summary
Facility staff failed to ensure proper storage and security of medications in several instances. Medications were found unsecured in the bathrooms of two residents, both of whom were cognitively intact but required staff assistance for activities of daily living. The medications observed included nasal spray, eye drops, cough syrup, ointment, antifungal cream, and zinc oxide cream. Additionally, a medication cart on one hall was left unlocked and unattended during medication administration. Further deficiencies were identified in the monitoring of medication refrigerator temperatures. Temperature logs for medication refrigerators on two separate halls were found to have multiple dates with missing entries, indicating that daily temperature checks were not consistently performed as required by facility policy. The Director of Nursing confirmed that these practices did not comply with facility protocols for medication security and storage.
Failure to Maintain Infection Control During Dining and Linen Handling
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as evidenced by staff not performing hand hygiene during meal service and improper storage of soiled linens. Specifically, a Certified Nursing Assistant (CNA) was observed assisting multiple residents with meal tray setup, including handling food items and straws with bare hands, and did not perform hand hygiene between resident interactions or before handling additional meal trays. These actions were observed during several consecutive resident meal setups, contrary to the facility's hand hygiene policy, which requires staff to clean their hands between resident contacts and after handling potentially contaminated items. Additionally, soiled linens and clothing were observed left on the floor in a resident's room at multiple times throughout the day. The resident involved had severe cognitive impairment and required assistance with activities of daily living. Facility policy states that soiled linens should be collected at the point of use and placed in a designated receptacle, and should not be left on the floor or in the resident's room. Staff interviews confirmed that these practices were not followed, and the Director of Nursing acknowledged that both hand hygiene and proper linen handling procedures were not maintained.
Deficiencies in Food Handling and Equipment Cleanliness
Penalty
Summary
The facility failed to ensure food was protected from contamination due to improper hand hygiene and handling practices by staff members. Observations revealed that a Certified Nursing Assistant (CNA) and the Admissions Coordinator touched food with their bare hands, and multiple staff members failed to perform hand hygiene before serving food or after touching potentially contaminated surfaces. Specifically, CNA C handled a dinner roll with bare hands and failed to sanitize her hands after picking up a roll from the floor. Similarly, CNA D did not perform hand hygiene before donning gloves to assist a resident with a meal, and CNA B placed a dirty meal tray back on a cart with clean trays. The facility also failed to maintain cleanliness in its ice machines, which were found to have white stains, dark discoloration, and biofilm or pink slime, indicating a lack of proper cleaning and maintenance. The ice machines, used by all halls, had visible build-up and discoloration, which the Administrator confirmed should not be present. The Maintenance Director admitted to not being sure about the cleaning frequency and confirmed that this was the first time he had deep cleaned the ice machine since taking the position. Additionally, the facility did not adhere to its policy on food storage, as evidenced by an observation of an opened, undated gallon of ice cream in the resident refrigerator, lacking a name or room number. The Dietary Manager confirmed that the ice cream should have been labeled with a name and date. These deficiencies highlight lapses in the facility's adherence to its own policies regarding hand hygiene, food handling, and storage, as well as equipment cleanliness.
Lack of Privacy for Resident Council Meeting
Penalty
Summary
The facility failed to provide a private space for the Resident Council Meeting, which compromised the residents' right to organize and participate in resident groups without interference. The meeting was held in the Activity Room, which had large openings on each side, making it accessible to anyone in the vicinity, including the 100 Hall, Administrators Offices, and Dining Room. No signs were posted to indicate that a meeting was in progress, and the environment was noisy, necessitating the use of a microphone to amplify the speaker's voice. During the meeting, several interruptions occurred, including the entry of the Assistant Director of Nursing, a housekeeper collecting trash, a visitor speaking to a resident, and a social worker standing in the doorway. Interviews with the Director of Nursing and the Activities Director revealed a lack of awareness regarding the need for a private setting for these meetings, with the Activities Director acknowledging that the meetings were typically held in the Activity Room and expressing an intention to find a more private location in the future.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in care planning. Resident #33, who was admitted with multiple diagnoses including diabetes, atrial fibrillation, and depression, was not care planned for monitoring the effects of anticoagulants, antibiotics, and diuretics. Despite having a BIMS score indicating cognitive intactness, the resident's care plan did not include necessary monitoring for bleeding, dehydration, and infection risks, as confirmed by the MDS Coordinator during an interview. Similarly, Resident #46, admitted with conditions such as peripheral vascular disease and chronic kidney disease, was not care planned for the management of an indwelling catheter. The resident, who had a BIMS score indicating moderate cognitive impairment, was observed with an indwelling urinary catheter in place, yet the care plan did not address this aspect of care. The MDS Coordinator acknowledged the absence of a care plan for the indwelling catheter during an interview, confirming the deficiency in care planning for this resident.
Failure to Update Care Plan Post-Fall
Penalty
Summary
The facility failed to update and revise the care plan for a resident who was reviewed for falls. The facility's policy, dated 3/5/2024, mandates that care plans be reviewed and revised when a resident experiences a status change. Resident #29, who was admitted with diagnoses of muscle weakness, ataxic gait, and psychotic disorder, had a BIMS score indicating cognitive intactness and required substantial staff assistance with most ADLs. The care plan dated 12/22/2020 identified the resident as at risk for falls, with an intervention for a medical doctor to evaluate on 1/22/2024. However, after an unwitnessed fall on 1/22/2024, the care plan was not updated with appropriate interventions. The Assistant Director of Nursing confirmed that an intervention should have been added post-fall.
Resident Exposed to Accident Hazards Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that a resident was free from accident hazards, as evidenced by the presence of potentially dangerous items accessible to a cognitively impaired resident. Resident #65, who was admitted with multiple diagnoses including dementia and anxiety disorder, was observed at the nursing station going through drawers that contained items such as toothpaste, blunt point scissors, Clorox aerosol spray, and Sani Wipes. The resident had a Brief Interview for Mental Status (BIMS) score of 4, indicating cognitive impairment, which increased the risk of harm from accessing these items. Interviews with facility staff revealed a lack of proper supervision and storage of hazardous materials. A Certified Nursing Assistant (CNA) acknowledged that the resident should not have been going through the drawers, and the Director of Nursing (DON) and a Registered Nurse (RN) both confirmed that chemicals should not be stored unattended at the nursing station. The staff explained that the resident was kept at the nursing station to prevent falls, as she had a history of wandering and falling when left in her room. However, this measure inadvertently exposed her to accident hazards due to inadequate supervision and improper storage of potentially dangerous items.
Deficient Catheter Care Practices in LTC Facility
Penalty
Summary
The facility failed to provide appropriate indwelling urinary catheter care for two residents, leading to deficiencies in care. For Resident #45, who was severely cognitively impaired and dependent on staff for all activities of daily living, a CNA was observed performing catheter care improperly. The CNA left the resident uncovered while gathering supplies, cleaned the scrotum and catheter with the same washcloth, and failed to use a different part of the washcloth during the process, which is against the facility's policy. For Resident #56, who was also severely cognitively impaired and had an indwelling urinary catheter, a CNA failed to clean the over bed table or place a barrier before starting catheter care. The CNA did not perform hand hygiene after removing gloves and before donning a new pair, and failed to clean the shaft of the penis during the procedure. The Director of Nursing confirmed that these actions were not in compliance with the facility's policy, which requires proper hand hygiene and specific cleaning techniques during catheter care.
Failure in Dialysis Care Coordination
Penalty
Summary
The facility failed to ensure ongoing communication and coordination of care with the dialysis center for a resident requiring dialysis services. The facility's policy on hemodialysis, dated June 3, 2024, mandates collaboration with the dialysis facility to meet the resident's needs and ensure safe administration of dialysis treatment. However, the facility did not maintain consistent communication with the dialysis center, as evidenced by incomplete or missing dialysis communication forms for Resident #64. The forms lacked post-dialysis vital signs, weight, medication administered, and fluid intake information for several dates in May and June 2024. Interviews with the Assistant Director of Nursing (ADON) and the RN Charge Nurse at the dialysis clinic revealed lapses in communication and documentation. The ADON acknowledged that the facility should have copies of the dialysis communication forms for each visit and that the charge nurse should monitor these forms for accuracy. The RN Charge Nurse at the dialysis clinic reported inconsistent receipt of communication forms from the facility and noted that other nursing homes routinely send forms with their residents. The RN Charge Nurse also highlighted the absence of documentation regarding communication with the facility about the resident's condition or any issues during treatment.
Significant Medication Error Due to Non-Adherence to Physician Orders
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the administration of antihypertensive medications despite contraindicated blood pressure readings. The facility's policy requires that medications be administered by licensed nurses or authorized staff according to physician orders and professional standards, including holding medications if vital signs fall outside prescribed parameters. However, the medical records revealed that a resident with severe cognitive impairment and a history of hypertension was given Metoprolol Tartrate and Amlodipine Besylate on two consecutive days, despite having a diastolic blood pressure reading below the physician's specified threshold of 60. The resident's medical records indicated a systolic blood pressure of 101 and a diastolic blood pressure of 55 on one of the days, with no blood pressure recorded on the following day. The Assistant Director of Nursing confirmed that the medications should have been withheld due to the low diastolic blood pressure. This oversight in medication administration represents a significant medication error, as the facility did not adhere to the physician's orders to hold the medications under these circumstances.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored appropriately, as evidenced by unsecured and unattended medications found in the rooms of two residents. Resident #3, who was admitted with diagnoses including Dementia and severe cognitive impairment, was observed with a bottle of mentholated ointment on her over-bed table. The facility's policy allows for self-administration of medication only after an interdisciplinary team assessment, which had determined that Resident #3 was not capable of safely self-administering or storing medications. Despite this, the mentholated ointment was found in her room on multiple occasions, and the Director of Nursing confirmed that it should not have been there. Similarly, Resident #65, who also had a diagnosis of Dementia and cognitive impairment, was observed accessing a drawer at the nursing station containing 26 packages of vitamin A & D ointment and a tube of phytoplex. The Certified Nursing Assistant confirmed that the resident should not have been going through the drawers containing chemicals. The Director of Nursing acknowledged that medications should not be stored unattended in the nursing station drawers, indicating a lapse in the facility's medication storage protocols.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain infection prevention practices for five of seven sampled residents who required enhanced barrier precautions. The facility's policy, dated June 18, 2024, mandates the use of enhanced barrier precautions for residents with wounds or indwelling medical devices to prevent the transmission of multidrug-resistant organisms. However, observations revealed that staff did not adhere to these precautions, as evidenced by the lack of personal protective equipment (PPE) usage during care activities for residents with pressure ulcers, indwelling urinary catheters, and gastrostomy tubes. Resident #9, with a diagnosis of a stage 4 pressure ulcer, did not have PPE available for enhanced barrier precautions during wound care performed by an LPN, who was unaware of the requirement. Similarly, Resident #39, who had an indwelling urinary catheter, was observed receiving a shower from an occupational therapist assistant without PPE usage. Resident #45, also with an indwelling urinary catheter, received catheter care from a CNA without PPE, and Resident #56, with a similar condition, was observed in the same situation. Additionally, Resident #319, who required enteral nutrition via a gastrostomy tube, had medications administered by an RN without PPE. Interviews with staff, including the Director of Nursing and Assistant Director of Nursing, revealed a lack of awareness and implementation of enhanced barrier precautions. The Assistant Director of Nursing acknowledged that enhanced barrier precautions were an addition to standard precautions and were recommended for residents with wounds, catheters, and indwelling medical devices. However, the facility had not yet implemented these precautions, despite initial education in April and plans to implement them in June. The Director of Nursing confirmed that no residents were on enhanced barrier precautions at the time of the survey.
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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