Majestic Gardens At Memphis Rehab & Snc
Inspection history, citations, penalties and survey trends for this long-term care facility in Memphis, Tennessee.
- Location
- 131 N Tucker, Memphis, Tennessee 38104
- CMS Provider Number
- 445150
- Inspections on file
- 32
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Majestic Gardens At Memphis Rehab & Snc during CMS and state inspections, most recent first.
A resident with a history of psychotic disorder, dementia, and hypertension was discharged, but the facility did not refund the resident's personal funds within the required 30-day period. The responsible party confirmed the refund was received late, and facility staff acknowledged the delay.
The facility failed to maintain safe hot water temperatures and provide adequate supervision, resulting in dangerously elevated water temperatures and injuries to residents. Maintenance staff lacked proper training, and there was a significant communication breakdown among the staff. Additionally, improper use of a mechanical lift led to a resident's lumbar compression fracture, and another resident fell due to inadequate supervision.
The facility failed to provide information regarding a resident's right to formulate an Advance Directive for 21 of 32 sampled residents. Despite the facility's policy, medical records revealed no documentation indicating that residents or their legal representatives were informed about their right to formulate an Advance Directive upon admission. The Director of Nursing confirmed that this should have been done.
The facility failed to provide effective housekeeping and maintenance services, resulting in strong urine odors, dirty privacy curtains, standing water in sinks, and a loose handrail. Staff interviews revealed gaps in communication and follow-through on maintenance requests, compromising residents' right to a safe, clean, and comfortable environment.
The facility failed to ensure food was stored, prepared, and served under sanitary conditions. Staff used bare hands to handle food, and multiple food items were found unlabeled and undated. The deep fryer contained dark grease and crumbs, and uncovered noodles were observed on a shelf. The Certified Dietary Manager confirmed these practices were against the facility's policies.
The facility failed to maintain safe operating equipment in four shower rooms and one elevator. Shower stalls in multiple halls were capped off due to water issues, and the 200 hall elevator had been out of order for nearly a year.
The facility failed to treat all residents with dignity and respect when three staff members, including two CNAs and one LPN, did not knock or announce themselves before entering residents' rooms during dining. The DON confirmed that staff should knock before entering a resident's room.
The facility failed to notify the Ombudsman of an emergency transfer for a resident with multiple diagnoses, including dementia and congestive heart failure. The resident was transferred to a hospital after being found on the floor, but the facility did not document the notification to the Ombudsman. A staff member confirmed that the required list had not been completed or sent.
The facility failed to accurately assess residents for BIMS scores, falls, discharge disposition, and diagnoses. One resident's quarterly MDS lacked a required BIMS assessment, another had multiple falls not reflected in the MDS, and a third had a fall not updated in the MDS. Additionally, a resident's MDS inaccurately marked Quadriplegia instead of Paraplegia, and another's discharge MDS incorrectly indicated discharge to a hospital instead of home.
The facility failed to provide scheduled bathing assistance for two residents, as evidenced by incomplete Skin Check sheets and missed showers on multiple occasions. Interviews with staff confirmed the residents' scheduled shower days and the lack of documentation.
A resident with multiple medical conditions did not receive the required monthly catheter change as per the facility's policy and physician's orders. The Director of Nursing confirmed that the catheter was not changed as scheduled, which was documented in the medical records.
The facility failed to ensure secure medication storage when medications were left unattended in a resident's room and two medication carts were found unlocked and unattended. The DON and LPNs confirmed that medications should not be left unsecured.
The facility failed to maintain accurate medical records for a resident, documenting a neurological check at 12:45 PM when the resident was not present in the facility. The resident had multiple diagnoses and severe cognitive impairment, and the error was confirmed by the Director of Nursing.
Delay in Refunding Discharged Resident's Personal Funds
Penalty
Summary
The facility failed to provide timely conveyance of personal funds for one discharged resident. According to the facility's Resident Funds Policy and Procedure, residents' personal funds and a final accounting are to be conveyed within 30 days of discharge. Medical record review showed that a resident with diagnoses including psychotic disorder with delusions, dementia, and hypertension was discharged to another facility. Documentation and interviews confirmed that the resident's personal account refund was not mailed to the responsible party until well after the 30-day requirement had passed, with both the Business Office Manager and Administrator acknowledging the delay.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards, specifically by not maintaining safe hot water temperatures and not providing adequate supervision to prevent falls and injuries. Dangerous hot water temperatures ranging from 121°F to 142°F were found in multiple resident rooms and shower rooms, posing a risk of serious injury, harm, burns, or death to residents. The facility's maintenance staff lacked proper training and failed to monitor and adjust the hot water temperatures appropriately, leading to Immediate Jeopardy (IJ) for the residents' safety. Additionally, the facility's policies and procedures for water temperature safety were not followed, and there was a significant communication breakdown among the staff regarding the issue. The Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Maintenance Team Lead were all unaware of the correct water temperature ranges and failed to take immediate corrective actions when the dangerously high temperatures were discovered. The facility's failure to properly use a mechanical lift during the transfer of a resident resulted in actual harm, with one resident sustaining a lumbar compression fracture. Another resident fell and required an emergency room visit due to the facility's failure to implement one-on-one care. The facility's policies on fall prevention and management, as well as safe and proper resident handling, were not adequately followed, leading to these incidents. The facility's census was 131, and the Immediate Jeopardy for F-689 began on 4/29/2024 and was ongoing at the time of the report.
Failure to Inform Residents About Advance Directives
Penalty
Summary
The facility failed to provide information regarding a resident's right to formulate an Advance Directive for 21 of 32 sampled residents. The facility's policy, dated December 2023, mandates that upon admission, the facility will determine if the resident has executed an advance directive and, if not, will provide information regarding the formulation of an advance directive. However, the medical records of the sampled residents revealed no documentation indicating that the residents or their legal representatives were informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. For instance, Resident #1, who was admitted with diagnoses including Abnormal Weight Loss, Cerebral Palsy, Major Depressive Disorder, and Diabetes, had a BIMS score of 14, indicating cognitive intactness. Despite this, there was no documentation in the medical record to show that the resident was informed about their right to formulate an Advance Directive. Similarly, Resident #3, with severe cognitive impairment and diagnoses such as Osteoporosis with Current Pathological Fracture and Traumatic Brain Injury, also lacked documentation of being informed about Advance Directives. The deficiency was consistent across multiple residents with varying degrees of cognitive impairment and different medical conditions. For example, Resident #14 with moderate cognitive impairment and diagnoses of Weight Loss and Epileptic Seizures, and Resident #21 with severe cognitive impairment and diagnoses of Fracture and Anxiety, both lacked documentation of being informed about Advance Directives. The Director of Nursing confirmed during an interview that all residents should have been offered or educated about Advance Directives upon admission, but the facility failed to do so for the sampled residents.
Failure to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to provide effective housekeeping and maintenance services, resulting in a non-sanitary, non-orderly, and uncomfortable environment for residents. Observations revealed strong urine odors in multiple resident rooms and hallways, dirty privacy curtains, standing water in bathroom sinks and basins, and a loose handrail in the 100 Hall. Specific instances included yellow stains on fitted sheets, brown stains on privacy curtains, and clogged sinks with standing water containing black particles. These conditions persisted over several days, indicating a lack of timely and effective cleaning and maintenance interventions. Interviews with staff confirmed that the facility's cleaning and maintenance procedures were not being followed adequately. Staff I acknowledged that privacy curtains should be assessed and changed weekly but were found stained and unchanged over several days. CNA H admitted that the maintenance issue with a resident's sink had not been reported promptly, and Staff C confirmed that the sink issue had not been entered into the facility's reporting system. The Director of Nursing also confirmed that the loose handrail in the 100 Hall needed fixing but remained unrepaired for several days. The facility's policies on preventive maintenance and resident room cleaning were not effectively implemented, leading to unsanitary and unsafe conditions. Staff interviews revealed gaps in communication and follow-through on maintenance requests, contributing to the prolonged presence of odors, stains, and standing water. These deficiencies compromised the residents' right to a safe, clean, and comfortable environment, as mandated by the facility's policies and regulatory standards.
Failure to Maintain Sanitary Conditions in Food Storage, Preparation, and Service
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served under sanitary conditions. Staff were observed using bare hands to prepare food, and multiple food items in the kitchen were found to be unlabeled and undated. Specifically, there were opened and undated packages of coconut flakes, pancake waffles, corn nuggets, mangos, and various meats in the freezer. Additionally, sandwiches were found undated and unlabeled in a metal pan, and black eye peas in the refrigerator were dated beyond their discard date. The deep fryer contained dark brown grease and crumbs, indicating it had not been cleaned or the grease changed as required. Uncovered noodles were also observed sitting on a metal shelf in a Styrofoam container. These observations were confirmed by the Certified Dietary Manager (CDM), who acknowledged that the items should have been labeled, dated, and stored properly, and that the deep fryer grease should have been changed and the fryer cleaned as scheduled. Further observations revealed that a Cook/Dietary Aide used bare hands to handle bread rolls and slices of cheese, which were then left uncovered. The CDM confirmed that staff should not use bare hands to pick up food and should be wearing gloves when handling food. These actions and inactions by the staff led to the deficiency in maintaining sanitary conditions in food storage, preparation, and service, as per the facility's policies and professional standards for food safety.
Failure to Maintain Safe Operating Equipment
Penalty
Summary
The facility failed to maintain equipment in safe operating condition for four shower rooms and one elevator. Observations revealed that shower stalls in the 100, 200, 300, and 400 hall shower rooms were capped off due to issues with water coming out of both the sprayer and the shower head simultaneously, and the water not getting hot enough. The Maintenance Director confirmed these issues and stated that repairs would require accessing behind the walls. Additionally, the 200 hall elevator was found to be out of order with caution tape and an out-of-order sign, and it was confirmed by the Healthcare Consultant that the elevator had been non-functional for nearly a year.
Failure to Knock Before Entering Residents' Rooms
Penalty
Summary
The facility failed to treat all residents with dignity and respect when three staff members, including two CNAs and one LPN, did not knock or announce themselves before entering residents' rooms during dining. Specifically, CNA S entered Resident #2's room, CNA T entered Resident #15's room, and LPN U entered both Resident #26's and Resident #29's rooms without knocking or announcing their presence. This was observed during dining on Hall 300 and Hall 400. The Director of Nursing confirmed that staff should knock before entering a resident's room.
Failure to Notify Ombudsman of Emergency Transfer
Penalty
Summary
The facility failed to notify the Ombudsman of an emergency transfer for a resident. The facility's policy required that a copy of the transfer notice be sent to the Ombudsman, potentially as a list of residents on a monthly basis. Resident #66, who had multiple diagnoses including Metabolic Encephalopathy, Dysphagia, Aphasia, Hemiplegia, Dementia, Congestive Heart Failure, Hypertension, and Contracture of the Left Hand, was admitted to the facility and later transferred to a hospital for evaluation after being found on the floor. The facility did not provide documentation that the Ombudsman was notified of this transfer. During an interview, a staff member confirmed that the Ombudsman Emergency Transfer List had not been completed or sent, and they were only informed of this requirement on the day of the interview.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to accurately assess residents for BIMS scores, falls, discharge disposition, and diagnoses for five residents. Resident #41 was admitted with multiple diagnoses, including Congenital Diaphragmatic Hernia and Alcohol and Cocaine Abuse, but the quarterly MDS did not include a required BIMS assessment. Resident #47, with diagnoses including Diabetes and Heart Failure, had multiple falls documented in progress notes and care plans, but the MDS assessments incorrectly indicated no falls prior to admission or reentry. The MDS Coordinator confirmed these assessments were coded incorrectly for falls. Resident #66, admitted with diagnoses such as Metabolic Encephalopathy and Hemiplegia, had a documented fall that was not reflected in the MDS. The MDS Coordinator acknowledged this oversight. Resident #86, with Muscle Wasting and Paraplegia, had an MDS that inaccurately marked Quadriplegia instead of Paraplegia. Lastly, Resident #128, discharged with diagnoses including Sepsis and Bipolar Disorder, had a discharge MDS indicating a BIMS of 15 and discharge to a hospital, while a physician's order indicated discharge home with family. The MDS Coordinator confirmed the resident was discharged home, not to a hospital.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure that assistance with Activities of Daily Living (ADL) related to bathing was provided for two residents. Resident #1, who has diagnoses including Spastic Quadriplegic Cerebral Palsy, Chronic Kidney Disease, Diabetes, Hypertension, and Depression, was scheduled to receive showers twice weekly. However, the facility's Skin Check sheets revealed that Resident #1 did not receive showers on three scheduled dates in April 2024. Interviews with staff confirmed that the resident should have received showers twice weekly and that the Skin Check sheets were not completed for the missed dates. Similarly, Resident #80, who has diagnoses including Peripheral Vascular Disease, Pressure Ulcers, Heart Failure, Diabetes, and Adult Failure to Thrive, was also scheduled to receive showers twice weekly. The Skin Check sheets for March and April 2024 showed that Resident #80 missed several scheduled baths. Interviews with the Director of Nursing (DON) confirmed that the resident should have received showers on the specified days and that the Skin Check sheets were incomplete. The DON acknowledged the lack of documentation and confirmed the scheduled shower days for Resident #80.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and services for an indwelling catheter for a resident with multiple diagnoses, including obstructive uropathy. The facility's policy on Foley catheter care, revised in June 2023, aims to prevent urinary tract infections by ensuring proper catheter maintenance. However, a review of the medical record revealed that the resident's catheter was not changed as ordered on April 14, 2024. This was confirmed by the Director of Nursing during an interview on May 6, 2024. The resident, who was cognitively intact with a BIMS score of 15, had an indwelling catheter and was admitted with several medical conditions, including osteomyelitis, obstructive uropathy, hemiplegia, cerebral infarction, hypertension, and arteriosclerotic heart disease. The care plan specified that the catheter should be changed monthly and as needed, but this was not documented in the April 2024 Medication Administration Record. An observation on May 1, 2024, showed the resident resting in bed with the catheter in place, but the required catheter change had not been performed as per the physician's orders.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medication was stored securely in several instances. In one case, medication was left unattended in a resident's room. Specifically, two white pills were observed on the overbed table of a resident who was lying in bed and asked for water to take her medicine. The LPN responsible for administering the medication confirmed that she left the medications at the bedside because she got busy and did not return to administer them. Additionally, two medication carts were found unlocked, unattended, and out of staff's line of sight. The Back up medication cart, which contained various over-the-counter medications, was left unlocked at the 100 hall Nurse's station. The 100 hall medication cart was also found unlocked and unattended in the 200 hall. During interviews, the DON confirmed that medication carts should not be left unlocked and unattended. The DON also explained that one nurse was responsible for residents on both the 100 and 200 halls, leading to the decision to separate medications into two carts. The LPNs involved acknowledged that they should not have left medications unattended. These actions and inactions led to the deficiency in ensuring the secure storage of medications in the facility.
Inaccurate Documentation of Neurological Check
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident, identified as Resident #66. The resident's medical record contained an inaccurate neurological check. According to the facility's policy, neurological assessments must be documented with the exact time they are performed. However, a neuro check for Resident #66 was documented at 12:45 PM on 2/21/2024, despite the resident being transported to the emergency room and not present in the facility at that time. This discrepancy was confirmed through a review of the medical record and the prehospital patient record from the fire department, which indicated that the resident left the facility at 6:25 AM and returned at 12:55 PM on the same day. The Director of Nursing acknowledged the error during an interview, stating that the resident would have been on his way to the hospital at the time the neuro check was documented. Resident #66 was admitted to the facility with multiple diagnoses, including Metabolic Encephalopathy, Dysphagia, Aphasia, Hemiplegia, Cognitive Communication Deficit, Dementia, Congestive Heart Failure, Hypertension, History of Falling, and Contracture of the Left Hand. The resident had a severe cognitive impairment, as indicated by a BIMS score of 7. On 2/21/2024, the resident was found on the floor with an open area over the left brow, prompting the need for neurological checks. The inaccurate documentation of the neuro check at 12:45 PM, when the resident was not in the facility, highlights the failure to maintain accurate medical records as per the facility's policies.
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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