Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Green Hills Center For Rehabilitation And Healing during CMS and state inspections, most recent first.
The facility failed to maintain sanitary conditions in its food service department, with kitchen equipment found with buildups of unknown substances and improper food storage practices. Staff did not adhere to hygiene protocols, such as covering hair and performing hand hygiene. These deficiencies were confirmed by the Regional Food and Nutrition Director, highlighting a lack of adherence to facility policies.
The facility failed to maintain resident dignity during meal assistance, as staff members were observed standing over residents while assisting them with meals. This included residents with severe cognitive impairment and those who were cognitively intact but physically dependent. The Director of Nursing confirmed that staff should not stand over residents, indicating a breach of protocol.
The facility failed to maintain the confidentiality of residents' medical records, as observed during random checks. LPNs left computer screens open and unattended, displaying residents' names and room numbers. The Director of Nursing confirmed that this practice was against facility policy.
The facility failed to conduct quarterly care plan meetings for five residents, as required by their policy. Despite the residents' varying cognitive statuses, the facility did not document these meetings, indicating a lapse in adherence to their comprehensive person-centered care plan policy. The DON confirmed the requirement for quarterly meetings, underscoring the facility's non-compliance.
The facility failed to provide adequate ADL care and hygiene for three residents, resulting in deficiencies in personal hygiene and grooming. A resident with moderate cognitive impairment did not receive a shower for several weeks, while another resident's toenails were unkempt despite a physician's order for podiatry services. A third resident, severely cognitively impaired, did not receive scheduled showers, and their hair was observed to be unkempt. Staff interviews confirmed these deficiencies.
A high-risk resident with cerebral infarction and hemiplegia developed a stage 4 pressure ulcer on the left ear due to inadequate care and delayed interventions. The facility failed to document the injury promptly, lacked physician's orders for treatment, and delayed nutritional interventions. Observations showed the resident often lying on the affected side without a wound dressing, and the DON confirmed the injury was not addressed immediately.
A facility failed to ensure the safety of a resident with a history of substance use disorder, who frequently left against medical advice (AMA) and returned intoxicated. The resident, using a motorized wheelchair, navigated unsafe areas and consumed alcohol and delta-8 THC gummies. The facility lacked documentation of monitoring and education provided to the resident, and AMA forms were incomplete. Interviews revealed no systematic approach to ensure the resident's safety, despite acknowledgment of the facility's responsibility.
A resident with severe cognitive impairment returned to the facility with an indwelling urinary catheter, but the facility failed to obtain a physician's order and update the care plan until during the survey. Additionally, a CNA did not perform proper hand hygiene during catheter care, as confirmed by the DON.
The facility failed to properly store medications, with issues including mixing internal and external medications, storing toxic chemicals with medications, and leaving medication carts unsecured. LPNs and RNs confirmed these practices were inappropriate, and a discontinued medication was improperly stored in the medication room.
The facility failed to follow infection control practices, as two staff members did not properly store soiled linens and failed to wear PPE for Enhanced Barrier Precautions. Additionally, an LPN did not disinfect reusable medical equipment after use. The DON confirmed these actions were against the facility's policies.
The facility failed to protect a resident from neglect, resulting in a fall and hip fracture due to inadequate assistance during incontinence care. Additionally, two residents experienced verbal abuse from a CNA, causing psychosocial harm. The facility's policies on fall management, MDS assessment, and abuse prevention were not adequately followed, leading to delayed treatment and compromised care.
A resident with severe cognitive impairment and a need for extensive assistance fell from bed during incontinence care, resulting in a hip fracture. The care plan lacked specific safety interventions for the use of an air mattress and the resident's seizure diagnosis, leading to the incident.
A resident at high risk for falls and requiring extensive assistance with ADLs fell from bed and sustained a left hip fracture during incontinence care performed by a single CNA, despite the care plan indicating a need for a two-person assist. The facility's policies on fall management, MDS assessment, and care planning were not adequately followed, and the incident revealed inconsistencies in staff accounts and inadequate documentation and assessment of the resident's condition post-fall.
The facility failed to provide effective pain management for two residents due to delays in administering scheduled pain medications. An agency nurse was unable to log into the computer system on time, resulting in increased pain and harm for the residents. One resident with a femur fracture experienced severe pain and was unable to complete physical therapy, while another resident with multiple diagnoses, including cancer, reported severe pain due to delayed medication administration.
The facility failed to provide adequate grooming, incontinence care, timely call light response, and personal hygiene for six residents. Residents reported waiting for hours for assistance, being left in soiled conditions, and not receiving regular showers or baths. Observations confirmed poor hygiene and neglect, with residents found in dirty clothing and bedding. Interviews with staff and family members corroborated these findings, highlighting a lack of adherence to care plans and facility policies.
A resident with no cognitive impairment was inappropriately fitted with a wanderguard bracelet after going to a fenced courtyard, leading her to feel like she was in jail. The staff's actions did not align with the facility's policies on wandering and elopement, and the resident's complaints were not adequately addressed.
The facility failed to report allegations of verbal abuse and neglect to the state agency within the required 2-hour timeframe for three residents. The incidents involved verbal abuse and neglect by a CNA, and the delays in reporting ranged from 15 to 18 hours. Interviews with residents and staff confirmed the abuse and the reporting delays.
The facility failed to thoroughly investigate allegations of verbal abuse and neglect involving three residents. One resident reported not receiving a shower and being rudely treated by a CNA, while another resident and their roommate reported a confrontation with a CNA who made threatening remarks. The facility's investigations were incomplete, and the administrator did not interview all relevant staff or take immediate action to protect the residents.
The facility failed to communicate critical information about a resident's fall during their transfer to a hospital for neurological evaluation. The omission in both oral and written reports could have likely resulted in a delay of treatment.
The facility failed to administer medications as ordered for three residents. One resident missed 14 medications due to staffing issues, another did not receive Dupixent injections because the medication was unavailable, and a third missed 22 doses of IV Cefepime due to a reconstitution error and failure to reorder the medication.
The facility failed to identify and correct quality deficiencies when a resident exited the building unnoticed for 7.5 hours and another resident fell from bed during care, resulting in a left hip fracture. The facility did not follow its QAPI policy, and no root cause analysis or corrective actions were taken for these incidents.
A resident exited the building twice unnoticed on the same day due to inadequate supervision and failure to follow facility policies. Despite being brought back inside after the first incident, no new interventions were implemented, leading to the resident's second unsupervised exit. The facility's lack of investigation and staff training resulted in Immediate Jeopardy.
Sanitation and Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to maintain sanitary conditions in its food service department, as evidenced by multiple observations of unsanitary practices and conditions. Kitchen equipment, including the cooking stove, deep fryer, griddle, and ovens, were found with thick black and brown buildups of unknown substances. The ice machine had rusted screws, black buildup, and a pink substance, which was confirmed to be mold by the Maintenance Director. Additionally, food items were improperly stored, with many being opened, undated, and expired, including various meats, vegetables, and dairy products. Staff members were observed not adhering to hygiene protocols, such as failing to cover hair and facial hair, and not performing hand hygiene before and after glove use. Specific instances included dietary aides and chefs working without hairnets or facial hair coverings, and failing to wash hands after removing gloves or before food preparation. These lapses in hygiene practices were confirmed by the Regional Food and Nutrition Director, who acknowledged the necessity of these measures to prevent contamination. The facility's policies on food storage, sanitation, and hand hygiene were not followed, leading to the observed deficiencies. Food was left uncovered and unattended, and clean dishes were placed on soiled carts. The Regional Food and Nutrition Director confirmed that these practices were against the facility's policies, which require food to be covered when unattended and carts to be cleaned before use. The lack of adherence to these policies contributed to the unsanitary conditions observed during the survey.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect during meal assistance, as observed in multiple instances involving staff members. Certified Nursing Assistants (CNAs) K, L, M, and N, along with an MDS Nurse, were seen standing over residents while assisting them with meals. This action is contrary to the facility's Resident Rights document, which mandates that employees treat all residents with kindness, respect, and dignity. The Director of Nursing confirmed that staff should not stand over residents during meal assistance, indicating a breach of protocol. The report highlights specific cases involving five residents with varying degrees of cognitive impairment and physical dependency. Residents with severe cognitive impairment, such as those with Alzheimer's Disease, and those who are cognitively intact but physically dependent, were all subjected to this undignified treatment. Observations were made on different dates, showing a pattern of behavior that disregards the residents' rights to a dignified existence and self-determination, as outlined in the facility's policies.
Failure to Maintain Resident Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' medical records for 27 out of 119 residents during a random observation and medication administration. The facility's policy on Resident Rights, dated February 2011, mandates that employees treat all residents with kindness, respect, and dignity, including ensuring privacy and confidentiality. However, during an observation on the 200 Hall, a Licensed Practical Nurse (LPN) was found sitting away from the medication cart with the computer screen left open and unattended, displaying residents' names and room numbers. The LPN acknowledged that the screen should not be left open when unattended. Further observations on the 300 Hall revealed similar issues with another LPN leaving the computer screen open and unattended while entering residents' rooms. This resulted in the exposure of residents' names and room numbers. During an interview, the Director of Nursing confirmed that computer screens should not be left unattended with residents' information visible. These incidents demonstrate a failure to adhere to the facility's policy on maintaining the confidentiality of residents' medical records.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct quarterly care conference meetings for five residents, as required by their policy on comprehensive person-centered care plans. The policy mandates that each resident's care plan be developed and revised with their participation, and that care planning conferences be held quarterly. However, the facility did not provide documentation of these meetings for the residents in question, indicating a lapse in adherence to their own policy. Resident #9, with mild cognitive impairment, had no documented care plan meetings since June 2024. Resident #10, who had no cognitive impairment, last had a care plan meeting in March 2024. Resident #25, also cognitively intact, had a significant gap between meetings from June 2024 to February 2025. Resident #36, with no cognitive impairment, had a similar gap from July to December 2024. Lastly, Resident #39, who was cognitively intact, had no documented meetings after June 2024. The Director of Nursing confirmed the requirement for quarterly meetings, highlighting the facility's failure to comply with this standard.
Deficiencies in ADL Care and Hygiene for Residents
Penalty
Summary
The facility failed to provide adequate care and services related to activities of daily living (ADLs) for three residents, resulting in deficiencies in maintaining personal hygiene and grooming. Resident #5, who has moderate cognitive impairment and requires assistance with all ADLs, did not receive a shower or bath after January 7, 2025, as documented in the facility's records. The facility was unable to provide evidence that Resident #5 received the necessary hygiene care for the remainder of January 2025. Resident #9, with moderate cognitive impairment and requiring maximal assistance with bathing, was observed with long, thick, and unkempt toenails, indicating a lack of grooming and podiatric care. Despite a physician's order for podiatry services, the resident's toenails were not attended to, as confirmed by the Unit Manager. Resident #317, who is severely cognitively impaired and dependent on staff for ADLs, was scheduled for showers twice a week but had not received a shower since January 17, 2025. Observations revealed that Resident #317's hair was unkempt and uncombed, and interviews with staff confirmed the resident had not received the scheduled showers or daily grooming.
Failure to Prevent and Manage Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide adequate care and services for the prevention of pressure ulcers for a resident identified as high risk. The resident, who was admitted with diagnoses including cerebral infarction, hemiplegia, and muscle weakness, was found to have a stage 4 pressure injury on the left ear. The facility's policies on pressure ulcer prevention and care were not followed, as evidenced by the lack of documentation and timely intervention for the pressure injury. The resident's care plan indicated a high risk for pressure injury development, with a Braden Scale score of 12, categorizing them as high risk. Despite this, the facility did not document the pressure injury in the medical record on the date it was identified, nor were there any physician's orders for treatment or documentation of the injury's appearance and size. Observations revealed that the resident was often found lying on the left side without a wound dressing, and nutritional interventions were delayed. Interviews with the Director of Nursing confirmed that the pressure injury was observed on a specific date, but interventions were not immediately implemented. The DON acknowledged that the resident's positioning likely contributed to the development of the pressure injury and that a wound dressing should have been intact. The failure to document and address the pressure injury promptly, along with the lack of immediate nutritional interventions, highlights the facility's deficiency in providing necessary care to prevent and manage pressure ulcers.
Facility Fails to Ensure Safety of Resident with Substance Use Disorder
Penalty
Summary
The facility failed to ensure a safe and secure environment for a resident with a history of substance use disorder, leading to multiple incidents of the resident leaving the facility against medical advice (AMA) and returning intoxicated. The resident, who had a BIMS score indicating no cognitive impairment, was known to leave the facility to consume alcohol and delta-8 THC gummies, posing significant safety risks. Despite the facility's policy on substance use disorder, there was a lack of documentation and monitoring of the resident's condition upon returning from these excursions. The resident was observed leaving the facility in a motorized wheelchair, navigating unsafe areas such as a sloped driveway leading to a busy street. The facility's staff failed to document the times the resident left and returned, as well as the education provided to the resident about the risks of leaving AMA. Additionally, there was no evidence of the required 15-minute monitoring checks after the resident returned intoxicated, as ordered by the nurse practitioner. Interviews with facility staff, including the administrator, revealed a lack of a systematic approach to ensure the resident's safety while out AMA. The AMA forms were incomplete, missing critical information such as the responsible physician's signature, times, and witness signatures. The administrator acknowledged the facility's responsibility for the resident's safety but was unable to provide a concrete plan to address the ongoing safety concerns.
Deficiency in Catheter Care and Hand Hygiene
Penalty
Summary
The facility failed to provide appropriate services and treatment for an indwelling urinary catheter for a resident who was admitted with a catheter but did not have a physician's order for its use until during the survey. The resident, who had severe cognitive impairment and a history of a cerebral vascular accident, dysphagia, and a PEG tube, returned to the facility with the catheter, but the care plan was not updated to reflect this until the survey. Observations confirmed the presence of the catheter, and interviews with staff, including an LPN and the Director of Nursing, acknowledged the oversight in obtaining the necessary order and updating the care plan. Additionally, a CNA failed to perform proper hand hygiene during catheter care for the resident. After providing incontinent stool care, the CNA removed gloves but did not perform hand hygiene before donning a new pair of gloves to continue with catheter care. This failure to adhere to hand hygiene protocols was confirmed by the Director of Nursing, who emphasized the importance of hand hygiene in preventing healthcare-associated infections.
Improper Medication Storage and Management
Penalty
Summary
The facility failed to ensure proper storage of medications in several areas, leading to deficiencies in medication management. On the 200 Hall Medication Cart #1, disinfectant wipes were stored with heparin lock flushes without a separation barrier, and various oral medications were stored together with skin irritation treatments in a plastic container without a barrier. Additionally, a box of pain relief gel packets was found opened and undated. These storage practices were confirmed as inappropriate by LPN R, who acknowledged that internal and external medications should not be stored together, nor should toxic chemicals be stored with medications. On the 100 Hall Medication Cart #1, scopolamine patches were stored without a barrier alongside insulin injection pens and ondansetron injection. A bottle of liquid protein oral supplement was found opened and undated, and oral suspension medication was stored with various nasal sprays without separation. RN HH confirmed these storage practices were incorrect, emphasizing the need for separation and proper labeling. Furthermore, the 300 Hall Medication Cart #2 was left unsecured and out of sight by LPN O, which was acknowledged as inappropriate by the DON. In the 300 Hall Medication Room, a discontinued medication was improperly stored, which LPN Q confirmed should have been returned to the pharmacy or discarded.
Infection Control Deficiencies in PPE Use and Equipment Disinfection
Penalty
Summary
The facility failed to adhere to proper infection control practices as outlined by the CDC guidelines and the facility's own policies. Two staff members, a CNA and an LPN, did not properly store soiled linens and failed to wear appropriate PPE for Enhanced Barrier Precautions (EBP). Specifically, soiled linens were observed on the floor in the rooms of two residents, one of whom had a wound requiring EBP. The CNA admitted to placing the soiled linen on the floor, and the LPN was observed kicking the linen behind a door and later removing it without donning the required PPE. Additionally, the LPN failed to disinfect reusable medical equipment after use. In one instance, the LPN used a blood pressure machine and pulse oximeter on a resident and then placed the equipment back into the medication cart without cleaning or disinfecting it. The Director of Nursing confirmed that these actions were against the facility's infection control policies, which require the disinfection of reusable equipment and the use of gowns and gloves in rooms where EBP is necessary.
Neglect and Verbal Abuse in LTC Facility
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in actual harm. Resident #319, who had severe cognitive impairment, contractures, and hemiparesis, required two-person assistance for bed mobility and incontinence care. However, staff provided only one-person assistance, leading to the resident falling from the bed and sustaining a left hip fracture. The facility also failed to monitor the resident for adverse outcomes related to the fall, resulting in a delay of treatment for one day. Additionally, the facility did not report the fall to the receiving emergency department, compromising the safe transition of care. The facility's policies on fall management, MDS assessment, and abuse prevention were not adequately followed. The care plan for Resident #319 lacked focus and interventions for seizure diagnosis and behaviors associated with jerking motions or spasms during care. The air mattress safety interventions were also not included in the care plan. The staff involved in the incident, including the CNA and LPN, did not receive proper training on ADL care for residents on an air mattress, and there was a lack of documentation and follow-up assessment after the fall. In another incident, the facility failed to protect two residents from verbal abuse by a CNA. The CNA made verbal threats and derogatory statements to the residents, causing psychosocial harm. The facility's investigation into the abuse was delayed, and the CNA continued to work the remainder of the shift after the incident. The facility's policies on abuse prevention and reporting were not adequately implemented, leading to a failure to protect the residents from further harm.
Failure to Implement Person-Centered Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for Resident #319, who had severe cognitive impairment and required extensive assistance with bed mobility and transfers. Despite the resident's need for a two-person assist for bed mobility, the care plan did not include specific safety interventions for the use of an air mattress or for the resident's seizure diagnosis and associated jerking motions during care. This oversight led to an incident where the resident fell from the bed during incontinence care, resulting in a left hip fracture. The incident occurred when a CNA was providing incontinence care to Resident #319, who was lying on his side on an air mattress. The resident exhibited jerking movements and forcefully projected himself off the bed. The CNA attempted to catch the resident but was unsuccessful, leading to the fall. The facility's incident report incorrectly stated that there were no witnesses, although both the CNA and the resident's roommate witnessed the fall. The resident was subsequently taken to the emergency department, where a left hip fracture was confirmed. Interviews with facility staff revealed that the care plan did not adequately address the resident's needs. The CNA involved in the incident stated that the care plan indicated a one-person assist, contrary to the resident's documented need for a two-person assist. Additionally, the facility's former DON and MDS Coordinator acknowledged that the care plan lacked interventions for the resident's seizure diagnosis and the use of an air mattress. The facility's failure to implement the appropriate plan of care and establish necessary safety measures directly contributed to the resident's fall and injury.
Failure to Provide Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to provide a safe environment for Resident #319, who was at high risk for falls and required extensive assistance with activities of daily living (ADLs). Despite the resident's care plan indicating the need for a two-person assist for bed mobility and transfers, incontinence care was performed by a single CNA. During this care, the resident fell from the bed and sustained a left hip fracture. The incident report and subsequent interviews revealed inconsistencies in the accounts of the fall, with the CNA stating that the resident's body tensed and he projected himself off the bed, while the resident later claimed he was pushed. The facility's investigation did not substantiate the resident's claim of being pushed, but it did confirm that the resident fell and was injured during care that did not adhere to the prescribed two-person assist protocol. The facility's policies on fall management, MDS assessment, and care planning were not adequately followed. The resident's care plan lacked specific interventions for his seizure diagnosis and the use of an air mattress, which was identified as a contributing factor to the fall. The CNA involved in the incident had no documented training for ADL care, and the facility failed to provide documentation of any assessments performed related to the fall. Additionally, the facility did not document any continuing assessment for changes in the resident's condition post-fall, and there was no evidence that the resident was provided with appropriate pain management following the incident. Interviews with staff and family members highlighted further deficiencies in the facility's response to the fall. The former DON claimed to have performed a head-to-toe assessment and used a mechanical lift to return the resident to bed, but this was contradicted by other staff members who stated that no lift was used and the DON was not present. The resident's family member had to demand that the resident be sent to the hospital for X-rays, which revealed a left hip fracture. The facility's failure to adhere to care plans, provide adequate supervision, and properly document and assess the resident's condition resulted in actual harm to the resident.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for two residents, resulting in actual harm. Resident #221, who was admitted with a trochanteric fracture of the left femur and Type 2 Diabetes Mellitus, did not receive his scheduled pain medication on time. The delay was caused by an agency nurse's inability to log into the computer system to administer medications. As a result, Resident #221 experienced increased pain and was unable to complete his physical therapy session. The resident was observed grimacing and groaning in pain, and he reported that his pain medication was consistently late, impacting his ability to manage pain effectively. Similarly, Resident #224, who was admitted with multiple diagnoses including unspecified cord compression, malignant neoplasm of the lung and spinal cord, and neoplasm-related pain, also did not receive her scheduled pain medication on time. The delay in administering Morphine Sulfate ER and Methocarbamol resulted in the resident experiencing severe pain, rated as a 9 on a scale of 1-10. The resident's call light was activated to request pain medication, and it was noted that the nurse was behind on her medication pass due to login issues with the computer system. Interviews with staff revealed that the agency nurse, LPN #44, was unable to start her medication pass on time because she did not have the necessary login information for the electronic medical record system. This issue was communicated to the former Director of Nursing (DON), who confirmed that the login information was provided late. Additionally, another LPN confirmed that agency nurses often faced similar challenges, impacting their ability to administer medications promptly. The facility's failure to provide timely login information and support to agency staff directly contributed to the delay in pain management for both residents, resulting in actual harm.
Failure to Provide Adequate Personal Care and Timely Assistance
Penalty
Summary
The facility failed to provide adequate grooming, incontinence care, timely call light response, and personal hygiene for six residents. The facility's policies on answering call lights, bathing, and ADL support were not adhered to, resulting in residents experiencing neglect and poor care. Residents reported waiting for hours for assistance, being left in soiled conditions, and not receiving regular showers or baths as per their care plans. Observations confirmed that residents had dirty fingernails, unkempt hair, and were often found in soiled clothing and bedding. Resident #4, who had no cognitive impairment, reported being left wet for hours and not receiving regular showers. Resident #56, also cognitively intact, had long, dirty fingernails and reported not receiving a shower for weeks, relying on family members for grooming. Resident #81, with a history of heart failure, was found with oily, flaky hair and dirty fingernails, and reported not receiving a bath or shower for months. This resident was later admitted to the hospital for acute heart failure exacerbation, with the hospital noting poor hygiene. Other residents, including Resident #220, Resident #221, and Resident #368, also reported similar issues. Resident #220 received only a few showers and mostly sponge baths, while Resident #221, who was non-weight bearing, had to bear weight to get to the bathroom due to long wait times for assistance. Resident #368 reported not receiving any showers since admission and being left in soiled conditions for hours. Interviews with staff and family members corroborated these findings, highlighting a lack of adherence to care plans and facility policies, resulting in significant neglect and poor quality of care for the residents.
Inappropriate Use of Wanderguard Bracelet on Resident
Penalty
Summary
The facility failed to treat Resident #88 with respect, dignity, and care in a manner that promotes the maintenance and enhancement of her quality of life. Resident #88, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Cirrhosis of the Liver, and Depression, had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Despite this, a wanderguard bracelet was placed on her ankle without documented evidence of wandering, confusion, delirium, or exit-seeking behavior. This action was taken after Resident #88 went to the courtyard, an area she had access to and was fenced, without attempting to leave the facility premises. The resident expressed feeling like she was in jail and complained about the bracelet to multiple staff members, indicating that it made her feel controlled and restricted her ability to go outside for fresh air and activities she enjoyed, such as reading and coloring. The staff's decision to place the bracelet was based on a misunderstanding of her actions and did not align with the facility's policies on wandering and elopement, which require a resident to be at risk of leaving the facility or wandering without purpose. Interviews with various staff members, including LPNs and the Regional Nurse Consultant, revealed inconsistencies in the understanding and application of the facility's policies, further contributing to the inappropriate use of the wanderguard bracelet on Resident #88.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of verbal abuse and neglect to the state agency within the required 2-hour timeframe for three residents. Resident #53, who had no cognitive impairment and required substantial assistance with activities of daily living, was allegedly verbally abused and neglected. The incident was reported by a family member but was not communicated to the state agency until 18 hours later. Resident #53 confirmed the neglect and verbal abuse during an interview. Resident #56, also with no cognitive impairment, reported that a CNA verbally abused her and her roommate late at night. The incident was not reported to the state agency until 15 hours later. Resident #56 expressed fear and distrust towards the CNA, and the incident was corroborated by her roommate and other staff members. The facility's investigation revealed that the night supervisor and other staff were aware of the incident but did not report it promptly. Resident #81, who had no cognitive impairment and required care following a surgical amputation, reported a confrontation with a CNA who used derogatory language and threatened him. The incident was reported to the facility's administrator the next day, and the state agency was notified 15 hours after the incident occurred. Interviews with the residents and staff confirmed the verbal abuse and the delay in reporting. The facility's former DON acknowledged that the allegations should have been reported within 2 hours but were not.
Failure to Investigate Allegations of Verbal Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of verbal abuse and neglect involving three residents. One resident reported not receiving a shower for several days and being rudely treated by a CNA. The facility's investigation did not document the resident's refusal of care or include a care plan addressing such refusals. The former DON admitted to not questioning other residents or investigating the reasons behind the refusals, leading to an incomplete investigation. Another incident involved a resident who reported a confrontation with a CNA, who allegedly made threatening and derogatory remarks. The resident's roommate corroborated the allegations. Despite the severity of the claims, the facility's investigation was incomplete, as the administrator did not interview all relevant staff or the roommate. The administrator acknowledged the failure to conduct a thorough investigation and take immediate action to mitigate the risk of harm to the residents. The facility's investigation into the second incident revealed conflicting statements between the resident and the CNA. However, the administrator did not follow up on documented findings or interview all involved parties, resulting in an incomplete investigation. The residents involved expressed fear and anxiety due to the CNA's behavior, and the facility failed to protect them from further harm during the investigation.
Failure to Communicate Critical Information During Resident Transfer
Penalty
Summary
The facility failed to communicate appropriate information to the receiving facility during the transfer of a resident. Resident #319, who had severe cognitive impairment and a history of neurological issues, was transferred to a hospital for evaluation of neurological symptoms. However, the facility's nursing staff did not include information about a fall that the resident had experienced the previous day in both the oral and written reports to the hospital. This omission was confirmed during an interview with an LPN who stated that if he had known about the fall, he would have included it in the transfer form and report call. The facility's policy on transfer and discharge procedures requires that all necessary information be communicated to ensure a safe and effective transition of care. Despite this, the transfer form completed by the former DON and the report called in by the LPN did not mention the fall. The facility was also unable to provide an updated policy on transfer and discharge procedures. This failure to communicate critical information could have likely resulted in a delay of treatment for the resident at the emergency department.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered by the physician for three residents. Resident #321, who was admitted with multiple diagnoses including Multiple Sclerosis and fractures, did not receive 14 medications as ordered on a specific date. The Medication Administration Record (MAR) showed missing 6:00 AM medications, and there was no documentation explaining why the medications were not administered. Interviews revealed that the night shift nurse was unable to administer all medications due to being the only nurse on duty, and the subsequent nurse could not complete the remaining medications due to time constraints. Resident #370, admitted with diagnoses including Cellulitis and Methicillin Resistant Staphylococcus Aureus Infection, did not receive the Dupixent injection on two occasions because the medication was not available. The nurse failed to follow up with the pharmacy or clinician to ensure the medication was obtained. The Director of Nursing stated that it is unacceptable for a resident to miss a medication and expected the nurse to notify the pharmacy or clinician if an ordered medication is not available. Resident #372, admitted with diagnoses including infection and inflammatory reaction due to an unspecified internal joint prosthesis, missed 22 consecutive doses of the IV antibiotic Cefepime for sepsis. The issue arose when the medication was reconstituted with normal saline instead of glucose, and the Nurse Practitioner failed to reorder the medication. Interviews with the nursing staff and the Medical Director confirmed that the medication was not administered for eight days, and the Nurse Practitioner acknowledged the mistake.
Failure to Identify and Correct Quality Deficiencies
Penalty
Summary
The facility failed to identify and correct quality deficiencies when a resident exited the building in his wheelchair and remained unnoticed for 7.5 hours. The facility's policy on QAPI was not followed, as there was no root cause analysis or corrective action taken regarding staff supervision at the exit door. The Administrator admitted to not considering an in-service related to the front door or seeing the exit door as a problem, and no QAPI meeting was conducted to address the incident. The Medical Director also confirmed that he was not involved in a root cause analysis for this event. Additionally, the facility failed to document and address a fall incident where a resident fell from bed during incontinence care and sustained a left hip fracture. The QAPI meeting notes from June did not include any documentation of the fall that occurred in May. The Administrator could not explain why the incident was not documented. This failure to prevent an avoidable accident resulted in a major injury to the resident.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide an environment free from accident hazards and adequate supervision for Resident #106, who exited the building twice unnoticed on the same day. The first incident occurred when a staff member unlocked the front door for a visitor, allowing Resident #106 to follow the visitor out at 12:31 PM. Despite the Interim Director of Nursing and the Administrator noticing and bringing Resident #106 back inside, no new interventions were put in place. Resident #106 exited the building again at approximately 1:35 PM when another staff member unlocked the front door for a visitor, and he was not noticed missing until approximately 9:00 PM, 7 1/2 hours later. The facility's failure to investigate and determine the root cause of the first incident, as well as the lack of immediate corrective actions, contributed to Resident #106's second unsupervised exit. The facility's policies on accidents, incidents, and elopements were not followed, and staff members were not adequately trained or informed about monitoring the exit door. Interviews with various staff members revealed a lack of awareness and communication regarding Resident #106's risk of elopement and his statements about leaving the facility. Resident #106, a 77-year-old male with a history of hypertension, arthritis, homelessness, and a previous myocardial infarction, was found to have traveled a significant distance from the facility in his wheelchair before being lost from video surveillance. The facility's failure to provide adequate supervision and a safe environment resulted in Immediate Jeopardy, as Resident #106 was exposed to significant risks, including heavy traffic and cold weather conditions. The facility did not conduct a root cause analysis or implement new interventions following the incidents, leading to a citation for Immediate Jeopardy at F-689 with a scope and severity of J.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodcrest At Blakeford | 0.7 mi | ★★★★★ | 10 | 0 |
| The Health Center At Richland Place | 1.6 mi | ★★★★★ | 8 | 0 |
| Nashville Center For Rehabilitation And Healing Ll | 2.9 mi | ★★★★★ | 0 | 0 |
| Advanced Health Care Of Nashville | 4 mi | — | 0 | 0 |
| West Meade Place | 4 mi | ★★★★★ | 9 | 0 |
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