Northbrooke Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, Tennessee.
- Location
- 121 Physicians Dr, Jackson, Tennessee 38305
- CMS Provider Number
- 445401
- Inspections on file
- 29
- Latest survey
- April 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Northbrooke Post Acute during CMS and state inspections, most recent first.
Surveyors found that three residents with pressure ulcers did not receive prescribed wound treatments on multiple occasions, and pressure-reducing mattresses were not properly implemented or maintained as ordered. Observations confirmed missing or incomplete equipment and lack of documentation for required care, with the DON acknowledging missed treatments and delays in initiating wound care.
Staff failed to properly secure and store medications, leaving drugs unattended on medication carts, storing opened oral medications in cups, and keeping a resident's inhaler at bedside without proper labeling. Multiple medication carts were found unlocked, unattended, and with damaged drawers that allowed access to medications. Staff and management confirmed these practices were not in line with facility policy.
Surveyors found that food was stored unlabeled, undated, and beyond use-by dates, with some items placed on the freezer floor and staff personal items on workstations. Dirty containers, rusted equipment, and an ice machine with debris were observed, along with uncovered drinks and food trays stored with standing water. Staff failed to perform hand hygiene or change gloves when required during food preparation and service, and nourishment refrigerators/freezers lacked proper temperature logs and thermometers, with expired or unlabeled food present.
Three cognitively intact residents with complex medical conditions were not invited to or included in required quarterly care plan meetings, as confirmed by missing documentation and resident interviews. Facility staff acknowledged that residents and their representatives were not notified or involved in the care planning process, contrary to policy requirements.
Two cognitively intact residents with significant medical conditions were unable to access their personal funds during after-hours and weekends, despite having funds available and having authorized the facility to manage their finances. Multiple residents confirmed this lack of access, and staff interviews indicated that no process was in place to provide funds outside of regular hours, contrary to facility policy.
Three residents with complex medical conditions, including dementia, hemiplegia, and kidney failure, died while in care, and their account balances were not refunded to their families or estates within the required 30-day period. The facility's Accounts Receivable staff confirmed the refunds were processed late, contrary to facility policy.
The facility did not provide or document required information about advance directives to multiple residents, including those who were cognitively intact and those with severe cognitive impairment whose representatives should have been informed. Staff confirmed that forms were incomplete and there was no evidence of education, signatures, or whether residents were offered or declined advance directives.
The facility failed to obtain a physician's order for foley catheter care and did not implement enhanced barrier precautions for a resident with an indwelling catheter, as well as failed to administer and document multiple scheduled medications for another resident with complex medical needs. Staff confirmed the absence of required orders, documentation, and medication administration.
A resident with total dependency for transfers and a history of falls was transferred using an inappropriate mechanical lift after staff failed to consult the care plan or Kardex, relying instead on the resident's verbal instruction. This resulted in the resident sliding out of the lift during the transfer, though no injuries were observed. Staff and therapy documentation confirmed the resident required a Hoyer lift with two-person assistance, and the failure to follow these interventions led to the incident.
Staff failed to ensure that enteral feeding products, syringes, and flush solutions were properly labeled for two residents with PEG tubes. Observations showed missing or incorrect labels, including absent resident names, dates, rates, and nurse initials. Both nursing and administrative staff confirmed that labeling requirements were not met.
The facility failed to obtain physician orders, follow existing orders, and accurately care plan for oxygen therapy for three residents. One resident received oxygen therapy without a physician's order, another received higher oxygen flow rates than documented and without a corresponding order, and a third was given oxygen at a rate significantly above the physician's order. The DON confirmed that orders and care plans were not properly followed or documented.
The facility did not have an RN on duty for the required 8 consecutive hours on two days, as staffing schedules showed only 6.5 and 6.12 RN hours due to the assigned RN and MDS Coordinator leaving early. The Staffing Coordinator confirmed the shortfall in RN coverage.
The facility did not post the total number of staff and actual hours worked by licensed staff responsible for resident care on the Daily Staff Posting form for all days reviewed. The Staffing Coordinator confirmed that the postings were kept on the computer and not displayed as required.
A resident with multiple serious health conditions was admitted to hospice and had a documented change to DNR status, but the facility failed to update the medical record and computer system. As a result, staff initiated CPR when the resident became unresponsive, contrary to the resident's updated wishes. Staff interviews confirmed the new POST form was not properly uploaded or reflected in the records.
Surveyors identified multiple infection control deficiencies, including staff failing to perform hand hygiene, improper use and storage of PPE, soiled linens left on resident room floors, and reusable medical equipment not being disinfected between uses. Environmental cleaning lapses were observed, such as blood-tinged gauze found on a resident's floor. Signage for isolation precautions was missing, and staff provided care to residents on Enhanced Barrier or Contact Precautions without appropriate PPE. These issues were confirmed by staff and nursing leadership.
The facility failed to properly label and administer enteral feedings for two residents. One resident's feeding and water flush bags were repeatedly unlabeled, and staff added formula without proper documentation. Another resident's feeding and water flush rates were set incorrectly, and the bags were undated and unlabeled, as confirmed by the Interim DON.
The facility was found to have unsanitary conditions in food storage and preparation, including undated food items and carbon build-up on cooking equipment. Additionally, expired milk was served to residents, with staff failing to check expiration dates. The CDM acknowledged these issues and the potential fire risk posed by the equipment condition.
The facility failed to maintain sanitary conditions during meal service and did not adhere to infection control protocols. Staff, including CNAs and an LPN, neglected proper hand hygiene and PPE use, particularly during meal service and resident care. Observations showed repeated failures in hand hygiene and PPE use, with staff admitting to not following or understanding infection control policies.
The facility failed to maintain resident dignity as CNAs entered multiple residents' rooms without knocking or announcing themselves, breaching the facility's policy on resident respect and dignity.
The facility failed to maintain a sanitary environment in several resident rooms, with observations of strong urine odors, dirty linens, and unlabeled personal items. Interviews with the Interim DON confirmed these conditions violated the facility's policy on cleanliness and resident rights.
The facility failed to provide scheduled bathing assistance for three residents, as required by their care plans. Despite policies ensuring three showers a week, records showed numerous missed showers for residents needing substantial assistance. The Interim DON confirmed the expectation for adherence to scheduled care, indicating a lapse in policy implementation.
The facility failed to provide necessary wound care and implement pressure-reducing mattresses for two residents with pressure ulcers. One resident did not receive ordered treatments for sacral and hip wounds on multiple occasions, while another resident's negative pressure wound therapy was not documented as completed. Additionally, the second resident was not placed on the prescribed air mattress. Interviews confirmed that treatments should be documented and air mattresses used for severe pressure ulcers.
The facility failed to ensure nursing staff demonstrated independent competency, as observed with two LPNs requiring coaching during routine care tasks. LPN L was coached on proper glucometer cleaning and hand hygiene, while LPN O needed guidance on administering medication via a PEG tube.
The facility failed to securely store medications as required by policy, with an LPN leaving a medication cart unlocked and unattended, and medications found at a resident's bedside. The Interim DON confirmed these actions were against policy.
Failure to Provide Pressure Ulcer Care and Implement Pressure-Reducing Devices
Penalty
Summary
Surveyors identified that the facility failed to follow physician orders and provide appropriate pressure ulcer care for three residents with pressure injuries. Facility policy required prompt assessment, evidence-based interventions, and the use of pressure-reducing mattresses for residents at risk or with existing pressure ulcers. However, medical record reviews and observations revealed that prescribed wound treatments were missed on multiple occasions for all three residents, and pressure-reducing mattresses were not properly implemented or maintained as ordered. For one resident with diabetes, anemia, and hypertension, there were missed daily wound treatments for both an unstageable pressure ulcer on the left buttock and a stage 3 pressure ulcer on the sacrum, as documented in the Treatment Administration Record. Observations showed that the resident's pressure-relief mattress lacked the required pump, and the appropriate equipment was not in place until after surveyor intervention. The DON confirmed that wound treatments should be completed and documented per physician orders, and that the correct mattress setup was necessary for wound care. Another resident with cerebrovascular disease and hemiplegia, who was at high risk for pressure ulcers, also had multiple missed wound treatments for a stage 3 sacral ulcer. This resident was observed on a bolster mattress rather than the required low air loss mattress until the equipment was changed during the survey. A third resident with severe malnutrition, diabetes, and Alzheimer's had missed wound treatments for a left heel injury and did not have a treatment order entered for a newly identified sacral deep tissue injury. Observations confirmed the absence of a pressure-relieving mattress until it was installed during the survey. The DON acknowledged that treatments were not initiated promptly and that documentation was lacking for required care.
Failure to Secure and Properly Store Medications
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were properly stored and secured, as required by facility policy and professional standards. Multiple incidents were observed where staff left medications unattended and out of sight, including a vial of insulin left on a medication cart and oral medications stored in a cup on the cart. In one instance, opened oral medications intended for a resident were found in a medication cup inside the medication cart, and the responsible LPN confirmed these were not disposed of as required. Additionally, a resident's inhaler was found stored on an over-the-bed table without an opened date, and staff confirmed this was not an appropriate storage location. Further observations revealed that medication carts on several halls were left unlocked, unattended, and out of staff sight. Staff interviews confirmed that medication carts should not be left unsecured or unsupervised, and that medications should not be left on top of carts or at residents' bedsides. The Director of Nursing and other staff acknowledged these lapses in medication security and storage practices during interviews. Physical inspection of medication carts on multiple halls revealed significant structural deficiencies, including holes and cracks in the drawers. These defects were large enough to allow access to medications stored inside, and staff confirmed awareness of the damage but had not reported it to management. The facility's failure to maintain secure storage for medications and to ensure staff compliance with medication handling protocols resulted in multiple deficiencies related to medication security and storage.
Deficient Food Storage, Sanitation, and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure that food was stored, handled, prepared, and served under sanitary conditions, as evidenced by multiple direct observations and policy reviews. Food items were found unlabeled, undated, and stored beyond their use-by dates, with some items placed directly on the freezer floor. Staff personal belongings, such as purses and phones, were observed on workstations and equipment, and food storage containers and lids were dirty with sticky residue. Additionally, a metal table and stand had visible rust, the ice machine had fuzzy debris hanging from its filter, and food trays were stored with standing water. Drinks were left uncovered, and nourishment refrigerators/freezers lacked proper temperature logs and thermometers, with some containing expired or unlabeled food items and visible residue. Staff did not consistently perform hand hygiene or change gloves when required, such as after adjusting face masks, opening refrigerators, handling carts, or plating food. Multiple instances were observed where dietary staff continued food preparation activities without washing hands or changing gloves after potential contamination. These actions were in direct violation of the facility's own policies, which require handwashing after unloading supplies and before handling food, as well as proper glove use and hand hygiene during food preparation and service. Interviews with the Certified Dietary Manager (CDM) and Director of Nursing (DON) confirmed that the observed practices were not in compliance with facility policies. The CDM acknowledged that food should be labeled and dated, not stored past use-by dates, and that food trays should not be stored with standing water. The DON confirmed that nourishment refrigerators/freezers should be clean, contain only resident food items, and have daily temperature logs. The CDM also confirmed that staff personal items should not be on workstations, and that hand hygiene should be performed when donning or removing gloves and after handling potentially contaminated items.
Failure to Involve Residents in Person-Centered Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan conference meetings were held at least quarterly for three residents who were cognitively intact and eligible to participate in their person-centered care planning. Policy review indicated that residents and their representatives should be invited to participate in care plan meetings, with documentation maintained by the social services director or designee. However, medical record reviews for three residents with various diagnoses, including end stage renal disease, osteomyelitis, atrial fibrillation, heart failure, cerebrovascular disease, and dementia, revealed that neither the residents nor their representatives were invited to or attended care plan meetings following multiple Minimum Data Set (MDS) assessments. Documentation of invitations or attendance was missing for several quarterly and annual care plan meetings. Interviews with the residents confirmed that they were not aware of or had not attended any care plan meetings. Staff interviews further confirmed that the responsibility for inviting residents and documenting attendance was not fulfilled, and that meeting notes did not reflect resident participation or signatures. The facility was also unable to provide documentation for at least one required care plan meeting. These findings demonstrate a failure to involve residents in the development and implementation of their person-centered care plans as required by facility policy.
Failure to Provide Residents with Reasonable Access to Personal Funds
Penalty
Summary
The facility failed to ensure that residents who had authorized the facility in writing to manage their personal funds had ready and reasonable access to those funds. According to facility policy, residents or their authorized representatives should be able to withdraw funds upon request and receive them within a reasonable time period. However, during a Resident Council Meeting, multiple residents reported that they did not have access to their funds during after-hours and on weekends. Specifically, two cognitively intact residents with various medical conditions, including hemiplegia, metabolic encephalopathy, diabetes, and congestive heart failure, stated they were unable to access their accounts at night and on weekends and expressed a desire for such access. An interview with the Accounts Receivable Consultant revealed that the facility did not currently have a receptionist available to dispense cash to residents after hours or on weekends, although there was an awareness of the regulatory requirement and an ongoing effort to address the issue. Review of the residents' fund management statements confirmed that funds were available for both residents, but the lack of access outside of regular hours constituted a failure to honor the residents' rights to manage their financial affairs as outlined in facility policy.
Delayed Refund of Resident Account Balances After Death
Penalty
Summary
The facility failed to refund the account balances of three residents within 30 days of their deaths, as required by its Resident Trust Policy. The policy states that all resident trust funds must be surrendered to the resident or their authorized representative within three normal banking days upon discharge or within thirty days upon death. However, for all three residents reviewed, the refunds were processed significantly later than the required timeframe. Specifically, one resident with diagnoses including hemiplegia, pressure ulcer, vascular dementia, and depression died, and the refund was processed over a month later. Another resident with kidney failure, sepsis, Parkinson's disease, and hemiplegia also had their refund delayed beyond the 30-day requirement. The third resident, who had dementia, anxiety, and dysphagia, similarly experienced a late refund. The Accounts Receivable staff confirmed that these account balances were refunded late.
Failure to Provide Advance Directive Information and Documentation
Penalty
Summary
The facility failed to provide information to residents regarding their right to formulate an advance directive, as required by both facility policy and federal regulations. Policy review indicated that residents or their representatives should be given written information about their rights to accept or refuse medical or surgical treatment and to formulate an advance directive, either prior to or upon admission. However, for 13 out of 25 residents reviewed, there was no documentation that this information or education was provided. This included both cognitively intact residents and those with severe cognitive impairment, where representatives should have been informed. Medical record reviews for these residents revealed a consistent lack of documentation regarding whether advance directives existed or if residents or their representatives had been offered the opportunity to formulate one. In several cases, residents were cognitively intact and capable of making their own decisions, yet there was no evidence that they were informed of their rights. For residents with severe cognitive impairment, there was no documentation that their legal representatives were educated or given the opportunity to formulate an advance directive on their behalf. During interviews, facility staff, including the Administrator in Training and the Social Worker, confirmed that the forms used for advance directives were incomplete and lacked necessary information. They were unable to provide evidence of what education was given, whether residents or family members had signed or initialed forms, or whether residents had been offered, declined, or assisted with advance directives. This lack of documentation and incomplete process led to the deficiency cited by surveyors.
Failure to Obtain Physician Orders and Administer Medications as Ordered
Penalty
Summary
The facility failed to obtain a physician's order for foley catheter care for one resident and failed to follow physician orders for another resident, as evidenced by policy review, medical record review, observations, and interviews. For one resident, there was no physician order for the placement or care of an indwelling urinary catheter, and no documentation of the catheter's insertion was found in the medical record. Additionally, enhanced barrier precautions, which are required for residents with indwelling medical devices, were not ordered or implemented, and there was no signage indicating these precautions in the resident's room. Staff interviews confirmed the absence of required orders and documentation. Another resident, who was severely cognitively impaired and dependent for all activities of daily living, had multiple diagnoses including diabetes, hypothyroidism, and a history of psychotic disorder. Review of this resident's medication administration records (MAR) over several months revealed numerous instances where scheduled medications, including insulin, levothyroxine, divalproex, megestrol acetate, and risperidone, were not administered as ordered. There was no documentation or explanation for the missed doses, and the MAR contained multiple blanks for scheduled medication administrations. The DON confirmed that unsigned medication administrations should be considered as not given. The deficiencies were identified through a combination of policy review, medical record review, direct observation, and staff interviews. The lack of physician orders for catheter care and enhanced barrier precautions, as well as the failure to administer and document scheduled medications, were not in accordance with facility policy or physician instructions. These findings were confirmed by staff, including the DON and nursing staff, who acknowledged the absence of required documentation and orders.
Failure to Follow Transfer Interventions Results in Resident Fall
Penalty
Summary
The facility failed to follow established interventions to prevent falls for a resident identified as being at risk. According to the care plan and therapy documentation, the resident was totally dependent for transfers and required the use of a Hoyer lift with two staff assisting. Despite this, staff used a stand-up lift, which was not appropriate for the resident's condition, resulting in the resident sliding out of the lift during a transfer from wheelchair to bed. The incident occurred after a CNA, unfamiliar with the resident's transfer needs, relied on the resident's verbal instruction rather than consulting the care plan or Kardex, as required by facility policy. Interviews with staff and review of records confirmed that the care plan and Kardex clearly documented the need for a Hoyer lift and total assistance for transfers. Both the CNA involved and another CNA admitted they did not check the care plan or Kardex before attempting the transfer. The Therapy Director and DON also confirmed that the resident's transfer method had not changed and that staff are expected to review the care plan or Kardex prior to transferring residents. The failure to follow these documented interventions led to the resident's fall, though no injuries were observed at the time.
Failure to Properly Label Enteral Feeding Supplies for Residents with Feeding Tubes
Penalty
Summary
Staff failed to provide proper care and services for residents with enteral feedings by not ensuring that enteral feeding products, syringes, and flush solutions were correctly labeled. For one resident with a history of gastrostomy, dementia, cerebral infarction, and dysphagia, observations revealed that the enteral feeding and water bottle were hung without any labeling for rate, date, resident name, time, or nurse initials. Additionally, a syringe was found undated and opened, and at one point, the feeding and water bottle were labeled with the wrong resident's name. The responsible LPN confirmed these labeling errors during interviews. For another resident with gastrostomy status, dysphagia, and Parkinson's, the enteral feeding and water bottle were also not properly labeled, with only the resident's last name present. The RN confirmed that the enteral syringe should be labeled with the nurse's initials, date, and changed every 24 hours, which was not done. The DON stated that proper labeling should include date, rate, time, nurse initials, and resident name, which was not observed in these cases.
Failure to Obtain and Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not obtaining required physician orders, not following existing physician orders, and not accurately care planning for oxygen therapy. For one resident with acute respiratory failure and other comorbidities, the facility did not have a physician's order for the ongoing oxygen therapy observed during multiple visits, despite documentation in the care plan. Another resident with respiratory failure and a tracheostomy was observed receiving oxygen at higher flow rates than documented in the care plan, and there was no physician's order specifying the correct oxygen flow rate. The care plan for this resident also did not accurately reflect the oxygen therapy being provided. A third resident with chronic obstructive pulmonary disease had a physician's order for oxygen at 2L/min via nasal cannula, but was observed receiving oxygen at 8L/min on two separate occasions. Nursing staff confirmed that the oxygen should have been set at 2L/min as per the physician's order. The DON acknowledged that staff are expected to follow physician orders and ensure care plans are accurate, but these requirements were not met for the residents reviewed.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours per day, 7 days a week, as required. Review of the daily staffing schedules and working schedules for March and April 2025 revealed that on two specific days, there was no RN coverage for the full 8 hours; instead, only 6.5 and 6.12 RN hours were documented on those days. During an interview, the Staffing Coordinator confirmed the shortfall, stating that the assigned RN and MDS Coordinator had left early on those dates, resulting in insufficient RN coverage.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the total number of staff and the actual hours worked by licensed staff responsible for resident care on the Daily Staff Posting form for all 31 days reviewed. Policy review, daily staff posting review, and interviews confirmed that the required information was not posted as mandated. During an interview, the Staffing Coordinator stated that the staff postings were kept on the computer and were not posted or printed for the company, resulting in the absence of the required daily postings.
Failure to Maintain Accurate Code Status in Medical Records
Penalty
Summary
The facility failed to maintain accurate and up-to-date medical records regarding the code status and CPR directives for a resident with multiple complex diagnoses, including acute respiratory failure, pulmonary disease, congestive heart failure, chronic kidney disease, and diabetes. The resident was admitted to hospice care, and documentation indicated a change in code status to Do Not Resuscitate (DNR) with comfort measures, as reflected on a new POST form and hospice admission paperwork. However, the medical record and physician order sheet did not reflect this change, and the resident remained listed as full code in the facility's computer system. When the resident became unresponsive, staff initiated CPR based on the outdated code status in the computer system, and EMS continued resuscitation efforts. Interviews with facility staff confirmed that the process for updating and uploading new POST forms was not followed, and the new DNR order was not properly incorporated into the resident's medical record. This failure to maintain accurate and current medical records resulted in actions that were not consistent with the resident's documented wishes and hospice care plan.
Widespread Infection Control Lapses Involving PPE, Hand Hygiene, and Environmental Cleaning
Penalty
Summary
Multiple deficiencies in infection prevention and control practices were observed throughout the facility, involving both staff actions and environmental conditions. In several instances, staff failed to adhere to established protocols for hand hygiene, use of personal protective equipment (PPE), and proper handling of soiled linens. For example, a registered nurse did not perform hand hygiene or don appropriate PPE before handling a resident's PEG tube, and several staff members failed to wear gowns and gloves when providing care to residents on Enhanced Barrier Precautions or Contact Precautions. Additionally, soiled linens were found placed on the floors of residents' rooms by staff, rather than being properly stored in designated containers, as confirmed by both direct observation and staff interviews. Environmental cleaning and disinfection lapses were also documented. In one case, a blood-tinged gauze was found on the floor of a resident's room, and the Director of Nursing confirmed this was inappropriate. Reusable medical equipment, such as a wristlet blood pressure machine, was not disinfected between uses on different residents, and staff failed to clean equipment before returning it to common areas. Enteral syringes were not properly air-dried before being stored, and staff did not consistently perform hand hygiene before or after medication administration or after removing gloves, as required by facility policy and CDC guidelines. Signage and communication regarding isolation and precautionary measures were insufficient. Residents with orders for Enhanced Barrier Precautions or Contact Precautions did not have appropriate signage on their doors, and PPE caddies were not available in relevant hallways. Staff entered and exited rooms of residents on isolation precautions without wearing required PPE, and some residents were unaware of their isolation status. These deficiencies were confirmed through interviews with staff and the Director of Nursing, who acknowledged that proper procedures were not followed in these instances.
Failure to Label and Administer Enteral Feedings Correctly
Penalty
Summary
The facility failed to ensure proper labeling and adherence to physician orders for enteral feedings for two residents. Resident #43, who was moderately cognitively impaired and required maximum assistance with activities of daily living, was observed with an unlabeled enteral feeding bag and water flush bag on multiple occasions. The feeding was set at 70 ml/hr with a 55 ml/hr water flush, but the bags were not labeled with the formula or rate of administration. Staff N added 500 ml of Glucerna 1.5 to the feeding bag without proper labeling, and the time of addition was not initially recorded. Resident #73, diagnosed with multiple severe conditions including quadriplegia and acute respiratory failure, had a physician's order for Jevity 1.5 at 65 ml/hr with a 45 ml/hr water flush. However, observations revealed the feeding was incorrectly set at 55 ml/hr and the water flush at 100 ml every 4 hours, with both bags undated and unlabeled. The Interim Director of Nursing confirmed the discrepancies and adjusted the rates to match the physician's orders, acknowledging the failure to label and date the bags as required.
Sanitation and Expired Food Issues in Dietary Services
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and service, as evidenced by several observations and interviews. During a kitchen inspection, surveyors found opened and undated packages of tater tots, hamburger patties, and hashbrowns. Additionally, there was a significant carbon build-up on the cooking stove burners and a large skillet, which the Certified Dietary Manager (CDM) acknowledged could pose a fire risk. The CDM confirmed that food items should be dated and that the condition of the cooking equipment was unacceptable. Further deficiencies were noted in the serving of expired milk to residents. Two residents reported receiving sour milk, with one resident unable to drink it and another having already consumed it despite the unpleasant taste. A CNA confirmed that she encountered expired milk on breakfast trays but did not report it, although she did replace the spoiled milk for the residents. The Dietary Aide admitted to not checking expiration dates before placing milk on meal trays, assuming the milk was safe since it was stored in the refrigerator. The CDM confirmed that expired milk should not be served to residents.
Infection Control and Hygiene Deficiencies in Meal Service and Resident Care
Penalty
Summary
The facility failed to ensure food was served under sanitary conditions and did not follow proper infection prevention and control protocols. During meal service, three staff members, including two CNAs and an LPN, did not perform proper hand hygiene. Observations revealed that one CNA repeatedly failed to wash hands between handling meal trays and interacting with residents, which is a direct violation of the facility's hand hygiene policy. Additionally, the LPN was observed handling meal trays without performing hand hygiene after touching potentially contaminated surfaces. The facility also failed to adhere to enhanced barrier precautions for residents requiring such measures. In one instance, a CNA provided incontinent care to a resident without wearing a gown, placed soiled items on the floor, and did not perform hand hygiene after removing gloves. The same CNA was observed touching medical equipment with contaminated gloves. Another LPN entered a resident's room without PPE and handled medical procedures without following proper hygiene protocols. Housekeeping staff also entered a resident's room without PPE, indicating a lack of awareness or availability of necessary protective equipment. Interviews with staff, including the Interim DON, confirmed a lack of understanding and adherence to infection control policies. Staff admitted to not seeing or understanding enhanced barrier precaution signage and not knowing the proper procedures for handling soiled items. The Interim DON acknowledged that staff should wear appropriate PPE and perform hand hygiene during resident care and meal service, highlighting a systemic issue in the facility's infection control practices.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents by not ensuring that staff members knocked and announced themselves before entering residents' rooms. This deficiency was observed during a dining period on Hall 200, where Certified Nursing Assistant (CNA) A entered the rooms of multiple residents without knocking or announcing their presence. Specifically, CNA A was observed entering the rooms of Residents #14, #71, #66, and #23 without following the proper protocol. Similarly, CNA B was observed on the same day entering the rooms of several residents without knocking or announcing themselves. This included Residents #58, #18, #32, #52, #3, #14, #71, #56, and #66. The Interim Director of Nursing confirmed during an interview that staff are expected to knock and announce themselves before entering a resident's room, indicating a clear breach of the facility's policy on promoting and maintaining resident dignity.
Facility Fails to Maintain Sanitary Environment in Resident Rooms
Penalty
Summary
The facility failed to maintain a sanitary environment in 10 out of 59 resident rooms, as evidenced by multiple observations of unsanitary conditions. These included strong urine odors, dirty gloves, and towels on the floor in bathrooms, as well as unlabeled and uncovered bath basins and bedpans. Specific instances were noted in the rooms of several residents, where bathrooms had urine odors, unflushed toilets, and brown substances on toilet seats. Additionally, privacy curtains in some rooms were stained, and floors were littered with debris, crumbs, and personal items like toothbrushes and deodorants. Interviews with the Interim Director of Nursing confirmed that these conditions were not in compliance with the facility's policy on maintaining a clean and homelike environment. The DON acknowledged that dirty linens and incontinent pads should not be left on the floor and that resident rooms should be free of odors and debris. The observations and interviews highlighted a systemic issue with housekeeping and sanitation practices within the facility, affecting the residents' right to a safe and comfortable living environment.
Failure to Provide Scheduled ADL Assistance for Bathing
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL), specifically bathing and showering, for three residents. The facility's policy mandates that residents who are unable to perform ADLs independently should receive the necessary services to maintain personal hygiene. However, the review of medical records and ADL Verification Worksheets revealed that Resident #35, who was severely cognitively impaired and required substantial assistance, did not receive scheduled showers on multiple occasions from March to May 2024. Similarly, Resident #31, who was cognitively intact but required physical help for most ADLs, and Resident #74, who was also cognitively intact but needed substantial assistance, missed several scheduled showers during the same period. The Interim Director of Nursing (DON) confirmed that residents are assigned showers based on their preferences and are supposed to receive three showers a week. Despite this, the ADL Verification Worksheets showed numerous missed shower dates for the three residents, indicating a failure to adhere to the scheduled care plan. The Interim DON acknowledged that residents should receive showers according to their schedule and preferences, highlighting a lapse in the facility's adherence to its own policies and procedures regarding resident care and hygiene.
Failure in Pressure Ulcer Management and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services to promote the healing of pressure ulcers for two residents. Resident #73, who was admitted with quadriplegia, cerebral infarction, hypertension, and pressure ulcers, did not receive the ordered wound care treatments on multiple occasions. The Treatment Administration Record (TAR) indicated that the prescribed Santyl ointment and dressings for the sacral and right hip wounds were not administered on specific dates. The Regional Nurse Consultant confirmed the omissions, and the Administrator acknowledged that treatments should be completed as ordered. Resident #189, admitted with a stage IV pressure ulcer, malnutrition, dementia, and cerebrovascular accident, also did not receive the required wound care. The resident's care plan included negative pressure wound therapy, which was not documented as completed on a scheduled date. During an observation, it was noted that the resident was not on the prescribed air mattress, which was confirmed by the LPN responsible for the resident's care. The Interim Director of Nursing (DON) could not verify if the wound care was performed, and the LPN admitted to not completing the treatment due to time constraints. The facility's failure to implement a pressure-reducing mattress and ensure wound care treatments were administered as ordered contributed to the deficiency. Interviews with the Interim DON and the Administrator confirmed that the documentation should reflect all care performed and that residents with stage 3 or 4 pressure ulcers should have air mattresses. The lack of proper documentation and adherence to care plans led to the identified deficiencies in pressure ulcer management.
Deficiency in Nursing Competency and Independent Practice
Penalty
Summary
The facility failed to ensure that all licensed nurses demonstrated independent competency in providing care and services, as observed in two instances involving LPNs. During a medication administration observation, LPN L was seen cleaning a glucometer with a Sani wipe only once, contrary to the facility's protocol, and was coached by a Regional Nurse to wipe it three times. Additionally, LPN L was reminded to wash her hands upon entering a resident's room, indicating a lack of adherence to proper hygiene practices. In another observation, LPN O experienced difficulty administering medication via a PEG tube and sought guidance from the Unit Manager present in the room. The Unit Manager coached LPN O to apply light pressure to the syringe, suggesting that LPN O was not fully competent in the procedure. These observations highlight a deficiency in ensuring that nursing staff are independently competent in their roles, as coaching was required during routine care tasks.
Medication Storage Deficiency
Penalty
Summary
The facility failed to adhere to its policy regarding the secure storage of medications, resulting in a deficiency. During an observation, it was noted that a medication cart was left unlocked and unattended in one of the seven medication storage areas. This occurred when an LPN left the cart unsecured while attending to a resident. The LPN acknowledged the oversight when questioned, confirming that the cart should not have been left unlocked. This incident was corroborated by the Interim DON, who stated that medication carts should not be left unsecured and unattended. Additionally, a separate observation revealed that medications were left at a resident's bedside, specifically Latanoprost Ophthalmic eye drops, which are used to treat high pressure inside the eye due to glaucoma. The Interim DON confirmed that medications should not be left at the bedside, indicating a failure to comply with the facility's medication storage policy. These observations highlight lapses in the facility's procedures for ensuring that all drugs and biologicals are stored in locked compartments, as required by their policy.
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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