Signature Health Of Portland Rehab & Wellness Cent
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Tennessee.
- Location
- 215 Highland Circle Drive, Portland, Tennessee 37148
- CMS Provider Number
- 445306
- Inspections on file
- 17
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Signature Health Of Portland Rehab & Wellness Cent during CMS and state inspections, most recent first.
A resident with multiple medical conditions and moderate cognitive impairment experienced a severe weight loss of over 7% in one week. Despite facility policies requiring monitoring and intervention for significant weight changes, there was no evidence that the RD or staff implemented or documented any interventions or follow-up after the weight loss was identified. Staff interviews confirmed that the expected process for addressing nutritional risk was not followed, resulting in actual harm.
A resident with paraplegia and a neurogenic bladder suffered third-degree burns after urine from self-catheterization contacted a power strip placed in the bed by the administrator. Despite staff awareness of the resident's incontinence, use of multiple electronics in bed, and safety concerns, there was no documented assessment, care plan intervention, or consistent monitoring to address the risks. The lack of appropriate actions and oversight led to the resident sustaining severe electrical burns.
A resident with a history of respiratory failure and COPD, who had clearly documented full code status and a preference for resuscitation, was found unresponsive by nursing staff. Despite being aware of the resident's wishes and physician orders, staff did not initiate CPR, citing the resident's physical appearance. This failure to provide BLS/CPR as required led to a citation for substandard quality of care.
The facility failed to provide adequate supervision and maintain a safe environment, resulting in serious incidents including a resident being electrocuted by a power strip in bed and another resident suffering a fatal fall after being left unattended. Multiple residents were found with electrical devices and cords in their beds, and staff reported unclear procedures and insufficient training regarding electrical safety. The facility lacked proper documentation and protocols for testing and maintaining patient care-related electrical equipment, contributing to ongoing accident hazards.
A resident suffered third-degree electrical burns after urine contacted an energized power strip in bed, requiring emergency evaluation. The QAPI committee did not maintain documentation or monitor the effectiveness of interventions following the incident, and ongoing noncompliance with electrical safety practices was observed, including residents with charging cords in bed and a lack of care plan interventions.
A resident with paraplegia and a neurogenic bladder, who self-catheterized and had a history of incontinence, sustained third-degree electrical burns after urine leaked into a power strip placed in bed. The facility did not assess the resident's ability to use the power strip safely, failed to include necessary interventions in the care plan, and did not report the incident of neglect with physical harm to the State Survey Agency as required.
A resident with complex medical and behavioral needs was not permitted to return to the facility after hospitalization for acute confusion and infection. Despite stabilization and no evidence of ongoing aggression, the administrator informed hospital staff and the resident's family that the resident would not be allowed back, contrary to facility policy and regulatory requirements. Staff interviews indicated the resident's behaviors were related to his medical condition, and the resident was not given the option to return.
A resident with paraplegia suffered second-degree burns in a shower room due to a malfunctioning hot water heater that had been leaking steam and hot water. Despite multiple reports from staff about the issue, the shower room remained in use, and the Administrator's instructions to manage the problem were inadequate. The resident, unable to feel below the waist, was unaware of the danger until injured, highlighting a significant neglect in ensuring resident safety.
A resident with paraplegia sustained second-degree burns on the left foot due to a malfunctioning hot water heater in the shower room, which reached temperatures of 169°F. Despite prior reports of steam and hot water leaks, the facility failed to address the issue, leading to Immediate Jeopardy. Staff were instructed to manage the situation by turning on faucets in adjacent rooms, rather than shutting down the malfunctioning shower room.
A facility's administration failed to address a malfunctioning hot water heater, resulting in a resident suffering a major burn injury. Despite multiple reports from staff about the hazard, the Administrator did not take appropriate action to ensure safety, leading to Immediate Jeopardy citations for substandard care.
Failure to Address Severe Weight Loss and Nutritional Risk
Penalty
Summary
The facility failed to assess and address the nutritional status of a resident who experienced a severe weight loss of 7.07% within a one-week period. The resident, who had multiple diagnoses including metabolic encephalopathy, neurogenic bladder, BPH, diabetes, and a urinary tract infection, was moderately cognitively impaired and required assistance with eating. Despite a significant weight loss being documented, there was no evidence that the registered dietitian (RD) or facility staff implemented or documented any interventions to address the weight loss or prevent further decline. Facility policies required regular monitoring of weights, prompt notification of significant changes, and individualized nutritional interventions. The resident's weight dropped from 230.5 lbs to 214.2 lbs in one week, and subsequent laboratory results showed low total protein and albumin levels, indicating poor nutritional status. There was no documentation of RD follow-up or progress notes after the initial evaluation, and no evidence of reweighing or new interventions following the significant weight loss. Interviews with staff confirmed that the expected process for addressing significant weight changes was not followed, and the RD was not notified or did not document any follow-up actions. Staff interviews revealed that while CNAs reported poor intake to nurses and offered snacks, and nurses were aware of the need to monitor and report weight changes, the required escalation to the RD and implementation of further interventions did not occur. The DON and other staff confirmed that there was no RD documentation after the weight loss was identified, and the process for monitoring and addressing nutritional risk was not followed as outlined in facility policy. This failure resulted in actual harm to the resident.
Neglect Resulting in Severe Electrical Burns Due to Unsafe Use of Power Strip
Penalty
Summary
A deficiency occurred when a resident with paraplegia, bilateral leg amputations, and a neurogenic bladder sustained third-degree burns to 4% of his body after urine from a self-catheterization or incontinence episode contacted an energized power strip that was positioned in his bed. The resident, who was functionally dependent for many activities and had a history of incontinence, was provided a power strip by the facility administrator after his extension cord was removed. There was no documented assessment of the resident's ability to safely use the power strip, nor was there any care plan addressing the risks associated with electrical devices in the bed, despite the resident's known incontinence and use of multiple electronic devices in bed. Staff interviews and medical record reviews revealed that the resident frequently kept electronics, charging cords, and other items in his bed, and staff were aware of his incontinence and the risk of spillage during self-catheterization. Multiple staff members, including CNAs and nurses, observed the power strip in the bed and reported safety concerns to administration, but there was no evidence of consistent monitoring, intervention, or documentation of the resident's refusals or noncompliance. The care plan did not include interventions related to the safe use of electrical devices, noncompliance behaviors, or monitoring of self-catheterization competency, even though the resident was receiving medications that could cause drowsiness and further increase risk. On the day of the incident, the resident self-catheterized and subsequently experienced an electric shock, resulting in severe burns. The power strip was found melted and deformed, and the resident required emergency medical attention. Staff confirmed that no education or monitoring regarding the safe use of electrical devices in bed had been provided prior to the incident. The facility's failure to assess, monitor, and implement appropriate interventions to prevent physical harm constituted neglect and resulted in actual harm to the resident.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to initiate and provide Basic Life Support (BLS), including Cardiopulmonary Resuscitation (CPR), to a resident who was designated as full code status. According to the facility's policies and the resident's documented preferences, staff were required to perform CPR unless there was a written physician order to the contrary. On the date of the incident, nursing staff found the resident unresponsive, without respirations or a palpable pulse, but did not attempt to perform BLS/CPR as required by both the resident's wishes and physician orders. The resident involved had a medical history that included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD) with acute exacerbation, and pneumonia. The resident was admitted and readmitted to the facility, with documentation confirming full code status and a clear preference for resuscitation efforts in the event of cardiac or respiratory arrest. The medical record, care conference notes, and the Tennessee Physician Orders for Scope of Treatment (POST) form all indicated the resident's desire for full code status, which was discussed and confirmed with both the resident and their representative. On the morning of the incident, the registered nurse assigned to the resident found them unresponsive during routine medication administration. Despite being aware of the resident's full code status, the nurse did not initiate CPR, citing the resident's physical appearance, such as blue fingers and discoloration of the lower extremities, as the reason. Another staff member was told by the nurse that the resident was a Do Not Resuscitate (DNR), which was not accurate. Interviews with other staff and the resident's family confirmed that the expectation was for life-saving measures to be performed in accordance with the resident's wishes. The facility's failure to provide BLS/CPR as required resulted in a citation for substandard quality of care.
Failure to Prevent Accidents and Maintain a Safe Environment
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free from accident hazards, resulting in avoidable accidents involving five residents. One resident, a bilateral amputee with paraplegia and neurogenic bladder, was electrocuted while lying in bed after urine contacted an energized power strip that had been provided by the Administrator and placed in the resident's bed. This incident resulted in third-degree burns to 4% of the resident's body. Staff and other residents reported that the resident frequently kept electronic devices and cords in bed, and concerns about safety had been voiced to administration, but no effective interventions were implemented to prevent the accident. Staff interviews revealed a lack of clear procedures for approving and monitoring electrical devices, and maintenance did not keep logs or have a set schedule for checking cords and devices. Another resident, who was cognitively impaired, legally blind, and at high risk for falls, was left unattended in the bathroom after being assisted there by staff. The resident stood up and fell, sustaining a left pubic root fracture that resulted in a fatal hemorrhage. The cause of death was documented as blunt force injury of the pelvis. The resident's care plan identified a high risk for falls and required staff assistance with transfers, but staff failed to provide the necessary supervision at the time of the incident. The resident had a history of falls and required substantial assistance with mobility and activities of daily living. Additional residents were observed with electrical devices and charging cords in their beds or attached to bed rails, despite care plans noting noncompliance with electrical device safety. Staff and residents reported that concerns about electrical hazards were not addressed until after state surveyors were present. Facility documentation revealed a lack of policies and procedures for testing patient care-related electrical equipment according to NFPA standards, and numerous devices with deficiencies were identified without records of repair. Staff education on electrical safety was inconsistent or lacking, and there was no evidence of systematic monitoring or enforcement of safety protocols related to accident hazards.
Failure to Implement and Monitor QAPI Interventions for Resident Safety
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee implemented and monitored effective interventions to maintain a safe environment for residents. Despite having a policy in place requiring systematic monitoring and evaluation of resident care, the QAPI committee did not maintain documentation of meeting minutes or evidence of monitoring the effectiveness of interventions following a serious safety incident. Staff interviews and observations revealed inconsistent compliance with education and monitoring related to electrical safety, and there was a lack of consistent oversight for electrical devices and power cords used by residents. An event occurred in which a resident was found in bed with third-degree electrical burns after urine contacted an energized power strip positioned in the bed. The resident required transfer to the emergency room for evaluation. Subsequent observations during the survey found ongoing noncompliance, with residents having charging cords in bed or attached to handrails without appropriate care plan interventions. The Maintenance Director confirmed inconsistent monitoring of electrical devices, and the Administrator was unable to provide QAPI meeting minutes or evidence of performance improvement evaluation related to the incident.
Failure to Report Neglect Resulting in Resident Injury
Penalty
Summary
The facility failed to report an incident of neglect with physical harm to the State Survey Agency as required by federal and state law. A resident with paraplegia, neurogenic bladder, and bilateral above-knee amputations, who was cognitively intact and performed self-catheterization, sustained third-degree electrical burns after urine leaked into a power strip that had been placed in the bed. The administrator had previously removed an extension cord from the resident's room and provided a power strip, but there was no documentation of an assessment to ensure the resident could use the power strip safely, nor was there a care plan addressing the safe use of electrical devices or education provided to the resident about the risks involved. Medical records indicated the resident had a history of incontinence and required assistance with personal hygiene and toileting. Despite this, the care plan did not include interventions for intermittent catheterization or address the resident's refusal of care. Staff documented episodes of incontinence, and the resident was known to keep electronics in bed. After the incident, the resident was sent to the emergency room and admitted for treatment of the burns, which covered approximately 4% of the body surface area. Interviews with facility staff, including the former assistant director of nursing, former director of nursing, and the administrator, confirmed that the incident was not reported to the State Survey Agency. Staff also acknowledged that the resident's competency in self-catheterization was not observed or documented, and that no interventions or education regarding the safe use of electrical devices were implemented prior to the incident. The administrator admitted to not reporting the accident as required by regulations.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, in violation of its own policy and federal regulations regarding resident rights to remain in the facility unless specific criteria for discharge are met. The resident in question had a complex medical history, including osteomyelitis, paraplegia, anxiety disorder, and an ileostomy, and was admitted and readmitted to the facility prior to the incident. Documentation showed that the resident experienced an acute episode of confusion, agitation, and combative behavior, which coincided with a urinary tract infection, sepsis, and metabolic encephalopathy. Staff documented that the resident was resistant to care, removed his colostomy bag, and swung a trapeze bar, but interviews with staff indicated that he had not been physically aggressive toward other residents and that his behavior was likely related to his acute medical condition. On the day of the incident, the resident was sent to the hospital for evaluation due to increased confusion and agitation. The facility completed an involuntary discharge notice, citing safety concerns and an inability to meet the resident's needs. The administrator delivered the resident's belongings and attempted to have the resident sign discharge paperwork at the hospital, despite being informed by hospital staff that the resident was not cognitively able to understand or sign the documents. Hospital case management notes and interviews confirmed that the administrator stated the resident would not be allowed to return to the facility, and this was communicated to both the hospital and the resident's family member. Multiple interviews with facility staff, hospital staff, the ombudsman, and the resident himself revealed that the resident was not offered the opportunity to return to the facility after his medical condition stabilized. The administrator maintained that the resident refused to return, but both the resident and his family member stated they were not given the option. The facility's actions were not consistent with its policy or regulatory requirements, as the resident's acute behavioral episode was related to a treatable medical condition, and there was no evidence that the facility could not meet his needs after stabilization.
Neglect Leads to Resident Burns Due to Malfunctioning Hot Water Heater
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in second-degree burns due to a malfunctioning hot water heater in the Station 2 shower room. The resident, diagnosed with paraplegia and requiring substantial assistance for showers, was exposed to scalding water when the hot water heater began gushing hot water and steam onto the floor. Despite multiple reports of the malfunctioning heater, the shower room remained in use, leading to the resident's injury. Staff, including CNAs and LPNs, had repeatedly observed and reported the hot water heater's issues, such as steam and hot water leaking into the shower room. The Director of Nursing and other staff members had informed the Administrator about the problem, but the shower room was not taken out of service. The Administrator instructed staff to manage the situation by turning on a faucet in an adjacent room, rather than addressing the root cause or closing the shower room. The resident, who had no feeling below the waist, was unaware of the scalding water until it caused burns. The incident was preventable, as staff had been aware of the ongoing issues with the hot water heater. The facility's failure to act on these reports and ensure a safe environment for the resident resulted in Immediate Jeopardy and actual harm to the resident.
Resident Burned Due to Hot Water Heater Malfunction
Penalty
Summary
The facility failed to maintain a safe environment for its residents, as evidenced by dangerously high hot water temperatures in the Station 2 shower room. This failure resulted in a vulnerable resident with paraplegia sustaining second-degree burns on the left foot. The incident occurred when the hot water heater malfunctioned, causing scalding water to spray onto the floor where the resident was seated. The water temperature was measured at 169 degrees Fahrenheit at the time of the incident. Interviews and documentation revealed that the facility had been aware of issues with the hot water heater prior to the incident. Staff reported multiple episodes of steam and hot water leaking from the heater, which had been occurring for several months. Despite these warnings, the facility did not take adequate measures to address the problem. The Administrator and Director of Nursing were informed of the malfunctioning heater, but the issue was not resolved, and the shower room continued to be used. The facility's inaction and improper handling of the hot water heater issue led to Immediate Jeopardy, as the malfunction posed a significant risk to resident safety. Staff were instructed to manage the situation by turning on faucets in adjacent rooms to relieve pressure, rather than shutting down the malfunctioning shower room. This inadequate response contributed to the resident's injury and highlighted a lack of effective communication and problem-solving within the facility.
Failure to Address Malfunctioning Equipment Leads to Resident Injury
Penalty
Summary
The facility administration failed to provide adequate oversight and supervision, resulting in a serious incident involving a malfunctioning hot water heater in the Station 2 shower room. Despite being notified of the issue on multiple occasions, the administration did not take appropriate action to address the hazard. The Director of Nursing (DON) and other staff members were aware of the malfunction, which caused scalding hot water to leak onto the floor, yet the shower room continued to be used for resident care. This negligence led to a major burn injury to a resident's left foot, highlighting a significant lapse in ensuring a safe environment. Interviews with staff revealed that the malfunctioning hot water heater had been reported to the Administrator and Maintenance Director prior to the incident. The DON acknowledged receiving a text message about the issue, and Licensed Practical Nurses (LPNs) reported observing steam and hot water leaking from the shower room. Despite these warnings, the Administrator dismissed concerns, suggesting that the water was not hot enough to cause harm and instructed staff to temporarily alleviate the issue by draining hot water from the heater. The Administrator's failure to take decisive action, such as shutting down the malfunctioning shower room, directly contributed to the resident's injury. The facility was cited for Immediate Jeopardy due to this oversight, with deficiencies noted under F-835, F-689, and F-600, indicating substandard quality of care. The report underscores the administration's responsibility to maintain a safe environment and protect residents from neglect and avoidable accidents.
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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