Knollwood Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Lafayette, Tennessee.
- Location
- 405 Times Ave, Lafayette, Tennessee 37083
- CMS Provider Number
- 445410
- Inspections on file
- 10
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Knollwood Manor during CMS and state inspections, most recent first.
The facility did not report multiple incidents of unexplained injuries—including skin tears, hematomas, abrasions, and discolorations—affecting several cognitively impaired residents, as required by policy and state regulations. Despite documentation of these injuries and internal notifications, the incidents were not reported to the state agency, and the Administrator confirmed that such reporting did not occur.
The facility did not conduct or document required investigations for injuries of unknown origin in six residents with cognitive impairment and multiple comorbidities. Despite policy requiring thorough investigation of incidents such as skin tears, hematomas, and abrasions, the facility was unable to provide investigation records for these events. Interviews with the DON and Administrator confirmed that investigations were not routinely performed or documented, resulting in a deficiency.
The facility did not consistently record daily temperatures for the refrigerator, freezer, and cooler as required by policy, resulting in food being stored and served without proper temperature monitoring. This deficiency affected 38 residents who received food trays during the period when temperature checks were not documented.
The facility did not properly track infections by organism or monitor for outbreaks, and failed to implement Enhanced Barrier Precautions for a resident with wounds. Staff did not post required signage or use appropriate PPE during wound care, despite facility policy and physician orders. Interviews confirmed that infection control protocols were not followed.
The facility did not hold or document required care plan meetings on admission and quarterly for two residents with significant medical conditions, failing to invite or involve the residents or their representatives as required by policy. The DON confirmed that documentation for these meetings was missing or that meetings had not been scheduled or completed.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for six residents as required by both facility policy and state regulations. Policy review indicated that any incident of unknown origin or suspicious in nature must be reported to the State of Tennessee within two hours, regardless of the resident's medical conditions. Despite this, multiple incidents involving injuries such as skin tears, hematomas, abrasions, and discolorations were documented in resident records and incident reports without subsequent notification to the state agency. The residents involved were all cognitively impaired to varying degrees, with several being severely impaired and unable to communicate the cause of their injuries. For example, one resident was found with a skin tear to the right forearm of unknown cause, another with a 6-inch hematoma to the left forearm, and others with abrasions or discolorations, all of which were unexplained. In each case, the facility completed internal documentation and notified responsible parties or physicians, but did not report the incidents to the state as required for injuries of unknown origin. During an interview, the Administrator acknowledged that incidents of unknown origin should be reported but admitted that these specific cases were not reported. The Administrator also indicated a reliance on staff trust and did not provide evidence of investigations that would rule out abuse or neglect. This lack of reporting and investigation for injuries of unknown origin constituted a failure to comply with both facility policy and state requirements.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to conduct complete and thorough investigations for injuries of unknown origin in six out of eight sampled residents reviewed for abuse. According to the facility's abuse policy, incident reports are required for all resident incidents, including falls, bruising, and skin tears, and each incident must be sufficiently investigated to determine the cause and include comments to prevent further injury. However, for each of the six residents cited, the facility was unable to provide documentation of any investigation accompanying the incident reports for injuries such as skin tears, hematomas, abrasions, and discoloration of unknown origin. The residents involved had significant cognitive impairments, as indicated by low BIMS scores, and multiple comorbidities such as Alzheimer's Disease, cerebral infarction, dementia, and chronic kidney disease. The incidents included findings such as a superficial skin tear, a large hematoma, a 1 cm skin tear, an abrasion, and purple discoloration, all with unknown causes. In each case, the incident was documented, but no investigation records were available to determine the cause or rule out abuse, as required by facility policy. Interviews with the DON and Administrator revealed that investigations into these incidents were either not conducted or not documented. The DON stated that discussions with staff about skin incidents are usually documented and attached to the incident report, but was unable to provide such documentation for the cited cases. The Administrator acknowledged that investigations were not routinely performed for incidents of unknown origin, often attributing injuries to resident behaviors or cognitive status without further inquiry or documentation. This lack of investigation and documentation led to the deficiency cited by surveyors.
Failure to Document Daily Food Storage Temperatures
Penalty
Summary
The facility failed to ensure that food was stored, handled, prepared, and served under sanitary conditions as required by both facility policy and professional standards. Specifically, the facility did not record the temperatures of the refrigerator, freezer, and cooler on multiple days throughout September 2025, as evidenced by a review of the Record of Refrigeration Temperatures. The facility's own policy mandates that the temperature of each freezer and refrigerator be checked and recorded daily to prevent contamination and bacterial growth. However, documentation was missing for several dates for each piece of equipment. During an interview, the Dietary Manager confirmed that temperatures for the refrigerator, freezer, and cooler should be checked and recorded daily. Despite this requirement, the lack of documentation indicates that this process was not consistently followed. As a result, 38 residents received food trays from the kitchen during the period when temperature monitoring was not properly documented.
Failure to Implement and Monitor Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and implement an effective infection prevention and control program as required by policy and regulation. The Infection Preventionist (IP)/Director of Nursing (DON) did not track infections by specific organisms, nor did they monitor for outbreaks or cross contamination among residents. Documentation reviewed, including the Nosocomial Infection Summary and Line Listing of Patient Infections, lacked information on the specific organisms involved in infections, and the IP/DON confirmed that such tracking was not performed. Additionally, there was no evidence that the facility monitored for cross contamination or investigated potential outbreaks, even when multiple urinary tract infections (UTIs) occurred on the same hallway within a month. For one resident, who had diagnoses including deep tissue damage, osteomyelitis, and malignant neoplasm of the prostate, the facility failed to implement Enhanced Barrier Precautions (EBP) as ordered by the physician. Observations revealed that EBP signage was not posted on the resident's door, and staff did not consistently use the required personal protective equipment (PPE) during wound care. Specifically, staff entered the resident's room, donned gloves but not gowns, and performed wound care without following the EBP protocol, despite being aware that the resident was under EBP. Interviews with staff, including an LPN and the Assistant Director of Nursing (ADON), confirmed that EBP signage should have been present and that both gown and gloves were required for wound care. The lack of signage and failure to use appropriate PPE during high-contact care activities demonstrated a breakdown in the facility's infection control practices, as outlined in their own policies and job descriptions.
Failure to Hold and Document Required Care Plan Meetings with Resident Participation
Penalty
Summary
The facility failed to ensure that care plan conference meetings were held on admission and quarterly for two residents, as required by both facility policy and federal and state standards. Facility policy mandates that a care plan meeting be held within seven days following a new comprehensive assessment and that these meetings be reviewed and updated at least quarterly, with the resident and/or their representative invited and encouraged to participate. Documentation of the meeting, including participant names and roles, is required, and if the resident or representative chooses not to participate, this must be documented. However, for one resident with diagnoses including traumatic subarachnoid hemorrhage, convulsions, cerebral infarction, and pain, there was no documentation that care plan meetings were held or that the resident or representative was invited following multiple MDS assessments, despite varying levels of cognitive function as indicated by BIMS scores. The care plan for this resident was last reviewed and revised on 9/15/2025, but required documentation for prior meetings was missing. Similarly, another resident with fractures of both femurs and seizures was admitted and had an admission MDS assessment indicating moderate cognitive impairment. The facility was unable to provide documentation that a care plan meeting was held or that the resident or representative was invited following the admission assessment. The care plan for this resident was also last reviewed and revised on 9/15/2025. During an interview, the Interim DON confirmed that she could not provide documentation for the required care plan meetings for either resident and acknowledged that a care plan meeting had not been scheduled or completed for the second resident.
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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