Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Humphreys County Care And Rehabilitation during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and complex medical conditions experienced significant weight loss, but recommended nutritional interventions from the RD were not communicated to or implemented by clinical staff. The DON and NP were unaware of the recommendations, and the facility failed to ensure timely follow-up, resulting in actual harm due to unmet nutritional needs.
The facility did not maintain an adequate emergency water supply as required by its policy, with only a 3-day supply of bottled water for drinking and cooking and two out of four hot water heaters not operational. The Administrator confirmed there was not enough water to meet the needs of all residents and staff for a 3-day emergency period.
The facility did not maintain a qualified Dietary Manager as required, leaving the kitchen without appropriate supervision after the previous DM resigned. Staff interviews revealed confusion about who was in charge, with a CNA and a cook temporarily filling supervisory roles despite lacking the necessary credentials. The Registered Dietician only visited twice monthly and was not managing the kitchen, resulting in noncompliance with staffing regulations.
Staff failed to maintain resident dignity during dining by addressing a resident with inappropriate endearments and serving meals in the hallway to three residents without care-planned preferences. The affected residents had significant cognitive impairments and required assistance, and staff interviews confirmed these actions were not in line with facility policy.
The facility did not provide written information on how to formulate an advance directive to several residents, as required by policy. Medical record reviews and staff interviews confirmed that neither residents nor their responsible parties received the necessary documentation, affecting individuals with a range of cognitive and medical conditions.
A resident with moderate cognitive impairment reported missing money from her nightstand on multiple occasions, but the allegation was not reported to State or local agencies as required by facility policy. Staff confusion and lack of communication led to the failure to follow mandated reporting procedures for suspected misappropriation of resident property.
A resident with moderate cognitive impairment reported missing money from her nightstand. The facility's investigation was limited to interviews with the resident and her responsible party, and an observation of money in the room, but did not include staff interviews or comprehensive documentation, resulting in a failure to thoroughly investigate the misappropriation allegation.
Two residents did not have comprehensive care plans reflecting their current needs and physician orders. One resident with severe cognitive impairment and multiple psychotropic and opioid medications lacked care plan documentation for medication use and monitoring. Another resident with hemiplegia and contractures did not have care plan interventions for passive range of motion or hand splint application, despite physician orders requiring these treatments.
The facility did not timely update care plans for two residents after significant changes in their conditions or treatments. One resident's care plan was not revised promptly after a fall, and another resident's care plan was not updated to reflect discontinued diuretic and psychotropic medications, despite these changes being known to staff.
Unsecured disposable razors and cleaning chemicals were found in the rooms of several residents, including those with cognitive impairment and physical dependency. Despite facility policies requiring immediate disposal of sharps and removal of hazardous items, these items were left unattended on bathroom sinks. RNs and the DON confirmed that such items should not be left unsecured.
Medications were found unsecured in the bathrooms of two residents who required staff assistance, and a medication cart was left unlocked and unattended during administration. Additionally, temperature logs for medication refrigerators on two halls were incomplete, with multiple dates missing required entries. The DON confirmed these practices did not follow facility policy.
Staff failed to perform hand hygiene between assisting multiple residents during meal service, including handling food and straws with bare hands, and did not properly store soiled linens, leaving them on the floor in a resident's room. These actions were not in accordance with facility infection control policies, as confirmed by staff and the DON.
The facility failed to protect food from contamination due to improper hand hygiene and handling by staff, including CNAs and the Admissions Coordinator. Observations showed staff touching food with bare hands and not performing hand hygiene. Additionally, ice machines were found with stains and biofilm, indicating poor maintenance. An opened, undated ice cream container was also found in the resident refrigerator, lacking proper labeling.
The facility did not provide a private space for the Resident Council Meeting, which was held in an open and noisy Activity Room. The meeting was interrupted multiple times by staff and visitors, and the DON and Activities Director were unaware of the need for privacy, leading to a failure in honoring residents' rights to organize without interference.
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in care planning. One resident was not care planned for monitoring the effects of medications, while another was not care planned for the management of an indwelling catheter. These omissions were confirmed by the MDS Coordinator during interviews.
A facility failed to update a care plan for a resident after an unwitnessed fall. Despite a policy requiring care plan revisions following status changes, the resident's care plan was not updated with appropriate interventions after the incident. The resident, who was at risk for falls and required substantial assistance with ADLs, did not have their care plan revised post-fall, as confirmed by the ADON.
A resident with cognitive impairment was found accessing potentially hazardous items at a nursing station, including scissors and aerosol sprays. Staff interviews revealed that the resident was kept at the nursing station to prevent falls, but inadequate supervision and improper storage of chemicals led to the exposure. The DON and RN confirmed that such items should not be stored unattended.
Two residents in an LTC facility received improper indwelling urinary catheter care. A CNA left one resident uncovered and used the same washcloth for cleaning both the scrotum and catheter. Another CNA failed to perform hand hygiene between glove changes and did not clean the shaft of the penis during catheter care. The DON confirmed these actions were against facility policy.
A facility failed to maintain consistent communication with a dialysis center for a resident requiring dialysis, as evidenced by incomplete or missing communication forms. The facility's policy requires collaboration with the dialysis center to meet the resident's needs, but interviews revealed lapses in documentation and communication. The ADON acknowledged the need for accurate monitoring of forms, while the RN Charge Nurse noted inconsistent receipt of forms from the facility.
A resident with severe cognitive impairment and hypertension was administered Metoprolol and Amlodipine despite having a diastolic blood pressure below the physician's specified threshold. The facility's policy requires holding medications if vital signs fall outside prescribed parameters, but this was not followed, leading to a significant medication error.
Two residents with cognitive impairments were found with unsecured medications in their rooms and at the nursing station. A resident had mentholated ointment in her room despite being assessed as unable to self-administer medications. Another resident accessed a drawer with ointments at the nursing station, which should not have been unattended. The DON confirmed these storage lapses.
The facility failed to implement enhanced barrier precautions for residents with wounds and indwelling medical devices, as required by their policy. Observations showed that staff did not use PPE during care activities for residents with pressure ulcers, urinary catheters, and gastrostomy tubes. Interviews revealed a lack of awareness and implementation of these precautions, despite initial education and plans to implement them.
Failure to Implement Dietician Recommendations for Residents with Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for two residents who experienced significant weight loss. Policy review showed that the facility was required to monitor weight changes and implement, monitor, and modify interventions as needed. For both residents, the Registered Dietician identified significant weight loss and recommended the addition of house supplements twice daily. However, these recommendations were not communicated to or implemented by the appropriate clinical staff. The Nurse Practitioner confirmed she was not made aware of the recommendations, and the DON acknowledged that the process for reviewing and acting on dietary recommendations was not followed due to staff absence and lack of follow-up. Both residents involved had complex medical histories, including severe cognitive impairment, dementia, and conditions such as aphasia, Parkinson's Disease, and adult failure to thrive. Despite documented weight loss—nearly 10% for one resident and over 5% for the other—there was no evidence that the recommended nutritional interventions were ordered or provided. The failure to implement these interventions resulted in actual harm to the residents, as the facility did not ensure their nutritional needs were met according to policy and clinical assessment.
Insufficient Emergency Water Supply Maintained
Penalty
Summary
The facility failed to ensure a sufficient emergency water supply was available for all 76 residents, as required by its own policy. The policy specified the amount of water needed for drinking, handwashing, cooking, toilet flushing, and miscellaneous uses, based on the number of residents and staff. During observation and interviews, it was found that only a 3-day supply of bottled water for drinking and cooking was maintained by the Dietary Manager. Additionally, in the boiler room, two out of four hot water heaters, each with a capacity of 116 gallons, were not operational, with one having its front panel missing and both turned off. The Business Office Manager confirmed the limited operational capacity, and the Administrator acknowledged that the facility did not have enough water to maintain a 3-day emergency supply for the average number of 52 employees and all residents.
Failure to Maintain Qualified Dietary Management Staff
Penalty
Summary
The facility failed to employ sufficient and qualified dietary staff to manage the food and nutrition service for all 76 residents. The job description for the Director of Food Services requires a graduate of an accredited dietetic program, at least five years of supervisory experience in a medical facility, and registration as a Food Service Director in the state. However, interviews and observations revealed that the facility did not have a Dietary Manager (DM) at the time of the survey, as the previous DM had quit approximately two weeks prior. Staff interviews indicated confusion and lack of clarity regarding who was supervising the kitchen, with a Certified Nursing Assistant (CNA) temporarily called in to fill the DM role, but also being assigned to CNA duties on the resident care floor. Further interviews with dietary staff, the Registered Dietician (RD), and the Administrator confirmed that the kitchen was being supervised by a cook, who did not hold the required qualifications for the DM position. The RD only visited the facility twice a month and was not managing the kitchen. The Administrator acknowledged that there was no current DM, and the cook was acting as the supervisor. This lack of qualified dietary management resulted in the facility not meeting regulatory requirements for food and nutrition service staffing.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to maintain resident dignity and respect during dining, as evidenced by staff not using courtesy titles and serving meals in the hallway without care planning for such preferences. Specifically, a registered nurse addressed a moderately cognitively impaired resident using terms such as "honey," "baby," and "babydoll" during meal service, contrary to facility policy which requires the use of courtesy titles and prohibits the use of endearments. Additionally, certified nursing assistants served meals to three severely cognitively impaired residents in the hallway while they were seated in Geri-chairs or Broda chairs, despite none of these residents having care plans indicating a preference for hallway dining. Medical record reviews confirmed that the affected residents had significant cognitive impairments and required staff assistance for activities of daily living, including eating. Observations documented that meals were provided and assistance was given in the hallway rather than in designated dining areas or according to resident preference. Interviews with facility staff, including the RN, MDS Coordinator, and DON, confirmed that serving meals in the hallway without care planning and failing to use appropriate forms of address were not in accordance with facility policy or resident rights.
Failure to Provide Written Information on Advance Directives
Penalty
Summary
The facility failed to provide written information on how to formulate an advance directive to 9 out of 24 sampled residents. Policy review indicated that the Admissions Director or designee is responsible for providing this information prior to or upon admission. However, medical record reviews for multiple residents with various diagnoses, including chronic illnesses and cognitive impairments, showed no documentation that either the residents or their responsible parties received the required written information regarding advance directives. Interviews with facility staff confirmed the deficiency. The Administrator acknowledged the facility's responsibility to provide written documentation on advance directives, and the Social Services Director stated that there was no current process in place to ensure residents received this information. The lack of documentation and process affected residents with a range of cognitive abilities, from cognitively intact to severely impaired, and included those with significant medical conditions such as COPD, heart failure, diabetes, and cancer.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that allegations of misappropriation of resident property were reported in accordance with its own policy and regulatory requirements. Specifically, a resident with moderate cognitive impairment reported missing money from the top drawer of her nightstand, both in her current and previous rooms. The resident was unable to specify the exact amount or date the money went missing, but stated it was mostly loose one-dollar bills. The allegation was brought to the attention of the Administrator, who was also the Abuse Coordinator, but there was confusion among staff regarding who was handling the report, and the Social Services Director was not aware of the specific allegation. Despite the facility's policy requiring immediate reporting of any misappropriation of resident property to the State Regulatory Agency within 24 hours, the allegation was not reported to State and local agencies. Interviews with the resident's nephew confirmed that the resident had reported missing money on multiple occasions, but he had not informed staff. The Administrator and Social Services Director demonstrated a lack of communication and follow-through, resulting in the failure to report the incident as required.
Failure to Conduct Thorough Investigation of Misappropriation Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of misappropriation of property involving a resident who reported missing money from the top drawer of her nightstand. The resident, who was moderately cognitively impaired with a BIMS score of 11 and had diagnoses including Ulcerative Colitis, Atrial Fibrillation, and Urinary Tract Infection, was unable to specify the exact amount or date the money went missing. The allegation was reported to the Administrator, and a grievance form was completed noting the missing money, with the resident's nephew estimating the amount at no more than $6.00 over the past month. The facility's investigation included an interview with the resident, a telephone interview with the responsible party, and an observation of $6.00 hidden in a tissue box on the resident's nightstand. However, the investigation did not include interviews with staff or other residents who might have had knowledge of the incident, nor did it provide thorough documentation of all investigative steps or a comprehensive investigation summary. The Administrator confirmed that a thorough investigation should have included these elements to determine the root cause and resolution of the allegation.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by its own policy. For one resident with severe dementia, depression, and anxiety, the care plan did not address the use of multiple psychotropic and opioid medications, despite medical records showing active orders for antipsychotic, antidepressant, antianxiety, anticonvulsant, and opioid drugs. The resident's care plan lacked documentation on monitoring for side effects or interventions related to these medications, even though specific monitoring instructions were present in the physician's orders. The MDS Coordinator confirmed that the care plan should have included these elements. For another resident with hemiplegia, contractures, and joint derangement, the care plan did not include interventions for passive range of motion (PROM) or the application of hand splints, despite physician orders specifying their use for contracture management. The resident's medical record indicated limited range of motion and the need for both left and right hand splints, but these interventions were not reflected in the care plan. The MDS Coordinator acknowledged that the care plan should have addressed the current use of hand splints and PROM.
Failure to Timely Update Care Plans After Significant Changes
Penalty
Summary
The facility failed to update or revise care plans for two residents following significant changes in their conditions or treatments. For one resident with a history of bipolar disorder, lower back pain, and vertebral fractures, the care plan was not updated in a timely manner after a fall incident. The fall occurred on 8/8/2025, but the care plan was not revised to include new interventions until 9/3/2025. The MDS Coordinator confirmed that interventions should have been added the next working day, but this did not occur. For another resident with anxiety, delusions, depression, and dementia, the care plan continued to include interventions related to diuretic and psychotropic medications even after these medications had been discontinued as of 7/16/2025. The care plan was not revised to reflect this significant change in the resident's medication regimen. The MDS Coordinator confirmed that the care plan should have been updated to reflect the discontinuation of these medications.
Unsecured Sharps and Chemicals Found in Resident Rooms
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by allowing unsecured sharps and cleaning chemicals to be present in the rooms of five sampled residents. Policy review indicated that contaminated sharps should be immediately discarded into designated containers, and items posing risks to residents' health and safety should be confiscated if found in plain view. Despite these policies, observations revealed that disposable razors and cleaning chemicals were left unsecured in resident bathrooms. Registered nurses confirmed during interviews that these items should not have been left unattended or unsecured in resident rooms. The residents involved had varying degrees of cognitive impairment and physical dependency, including diagnoses such as dementia, depression, hypertension, heart failure, and respiratory conditions. Some residents required moderate to total assistance with activities of daily living. The unsecured items included disposable razors, aerosol air freshener, disinfectant spray, and surface cleaner, all found on or under bathroom sinks. The Director of Nursing confirmed that these items should not have been left unsecure and unattended in residents' rooms.
Medication Storage and Security Deficiencies
Penalty
Summary
Facility staff failed to ensure proper storage and security of medications in several instances. Medications were found unsecured in the bathrooms of two residents, both of whom were cognitively intact but required staff assistance for activities of daily living. The medications observed included nasal spray, eye drops, cough syrup, ointment, antifungal cream, and zinc oxide cream. Additionally, a medication cart on one hall was left unlocked and unattended during medication administration. Further deficiencies were identified in the monitoring of medication refrigerator temperatures. Temperature logs for medication refrigerators on two separate halls were found to have multiple dates with missing entries, indicating that daily temperature checks were not consistently performed as required by facility policy. The Director of Nursing confirmed that these practices did not comply with facility protocols for medication security and storage.
Failure to Maintain Infection Control During Dining and Linen Handling
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as evidenced by staff not performing hand hygiene during meal service and improper storage of soiled linens. Specifically, a Certified Nursing Assistant (CNA) was observed assisting multiple residents with meal tray setup, including handling food items and straws with bare hands, and did not perform hand hygiene between resident interactions or before handling additional meal trays. These actions were observed during several consecutive resident meal setups, contrary to the facility's hand hygiene policy, which requires staff to clean their hands between resident contacts and after handling potentially contaminated items. Additionally, soiled linens and clothing were observed left on the floor in a resident's room at multiple times throughout the day. The resident involved had severe cognitive impairment and required assistance with activities of daily living. Facility policy states that soiled linens should be collected at the point of use and placed in a designated receptacle, and should not be left on the floor or in the resident's room. Staff interviews confirmed that these practices were not followed, and the Director of Nursing acknowledged that both hand hygiene and proper linen handling procedures were not maintained.
Deficiencies in Food Handling and Equipment Cleanliness
Penalty
Summary
The facility failed to ensure food was protected from contamination due to improper hand hygiene and handling practices by staff members. Observations revealed that a Certified Nursing Assistant (CNA) and the Admissions Coordinator touched food with their bare hands, and multiple staff members failed to perform hand hygiene before serving food or after touching potentially contaminated surfaces. Specifically, CNA C handled a dinner roll with bare hands and failed to sanitize her hands after picking up a roll from the floor. Similarly, CNA D did not perform hand hygiene before donning gloves to assist a resident with a meal, and CNA B placed a dirty meal tray back on a cart with clean trays. The facility also failed to maintain cleanliness in its ice machines, which were found to have white stains, dark discoloration, and biofilm or pink slime, indicating a lack of proper cleaning and maintenance. The ice machines, used by all halls, had visible build-up and discoloration, which the Administrator confirmed should not be present. The Maintenance Director admitted to not being sure about the cleaning frequency and confirmed that this was the first time he had deep cleaned the ice machine since taking the position. Additionally, the facility did not adhere to its policy on food storage, as evidenced by an observation of an opened, undated gallon of ice cream in the resident refrigerator, lacking a name or room number. The Dietary Manager confirmed that the ice cream should have been labeled with a name and date. These deficiencies highlight lapses in the facility's adherence to its own policies regarding hand hygiene, food handling, and storage, as well as equipment cleanliness.
Lack of Privacy for Resident Council Meeting
Penalty
Summary
The facility failed to provide a private space for the Resident Council Meeting, which compromised the residents' right to organize and participate in resident groups without interference. The meeting was held in the Activity Room, which had large openings on each side, making it accessible to anyone in the vicinity, including the 100 Hall, Administrators Offices, and Dining Room. No signs were posted to indicate that a meeting was in progress, and the environment was noisy, necessitating the use of a microphone to amplify the speaker's voice. During the meeting, several interruptions occurred, including the entry of the Assistant Director of Nursing, a housekeeper collecting trash, a visitor speaking to a resident, and a social worker standing in the doorway. Interviews with the Director of Nursing and the Activities Director revealed a lack of awareness regarding the need for a private setting for these meetings, with the Activities Director acknowledging that the meetings were typically held in the Activity Room and expressing an intention to find a more private location in the future.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in care planning. Resident #33, who was admitted with multiple diagnoses including diabetes, atrial fibrillation, and depression, was not care planned for monitoring the effects of anticoagulants, antibiotics, and diuretics. Despite having a BIMS score indicating cognitive intactness, the resident's care plan did not include necessary monitoring for bleeding, dehydration, and infection risks, as confirmed by the MDS Coordinator during an interview. Similarly, Resident #46, admitted with conditions such as peripheral vascular disease and chronic kidney disease, was not care planned for the management of an indwelling catheter. The resident, who had a BIMS score indicating moderate cognitive impairment, was observed with an indwelling urinary catheter in place, yet the care plan did not address this aspect of care. The MDS Coordinator acknowledged the absence of a care plan for the indwelling catheter during an interview, confirming the deficiency in care planning for this resident.
Failure to Update Care Plan Post-Fall
Penalty
Summary
The facility failed to update and revise the care plan for a resident who was reviewed for falls. The facility's policy, dated 3/5/2024, mandates that care plans be reviewed and revised when a resident experiences a status change. Resident #29, who was admitted with diagnoses of muscle weakness, ataxic gait, and psychotic disorder, had a BIMS score indicating cognitive intactness and required substantial staff assistance with most ADLs. The care plan dated 12/22/2020 identified the resident as at risk for falls, with an intervention for a medical doctor to evaluate on 1/22/2024. However, after an unwitnessed fall on 1/22/2024, the care plan was not updated with appropriate interventions. The Assistant Director of Nursing confirmed that an intervention should have been added post-fall.
Resident Exposed to Accident Hazards Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that a resident was free from accident hazards, as evidenced by the presence of potentially dangerous items accessible to a cognitively impaired resident. Resident #65, who was admitted with multiple diagnoses including dementia and anxiety disorder, was observed at the nursing station going through drawers that contained items such as toothpaste, blunt point scissors, Clorox aerosol spray, and Sani Wipes. The resident had a Brief Interview for Mental Status (BIMS) score of 4, indicating cognitive impairment, which increased the risk of harm from accessing these items. Interviews with facility staff revealed a lack of proper supervision and storage of hazardous materials. A Certified Nursing Assistant (CNA) acknowledged that the resident should not have been going through the drawers, and the Director of Nursing (DON) and a Registered Nurse (RN) both confirmed that chemicals should not be stored unattended at the nursing station. The staff explained that the resident was kept at the nursing station to prevent falls, as she had a history of wandering and falling when left in her room. However, this measure inadvertently exposed her to accident hazards due to inadequate supervision and improper storage of potentially dangerous items.
Deficient Catheter Care Practices in LTC Facility
Penalty
Summary
The facility failed to provide appropriate indwelling urinary catheter care for two residents, leading to deficiencies in care. For Resident #45, who was severely cognitively impaired and dependent on staff for all activities of daily living, a CNA was observed performing catheter care improperly. The CNA left the resident uncovered while gathering supplies, cleaned the scrotum and catheter with the same washcloth, and failed to use a different part of the washcloth during the process, which is against the facility's policy. For Resident #56, who was also severely cognitively impaired and had an indwelling urinary catheter, a CNA failed to clean the over bed table or place a barrier before starting catheter care. The CNA did not perform hand hygiene after removing gloves and before donning a new pair, and failed to clean the shaft of the penis during the procedure. The Director of Nursing confirmed that these actions were not in compliance with the facility's policy, which requires proper hand hygiene and specific cleaning techniques during catheter care.
Failure in Dialysis Care Coordination
Penalty
Summary
The facility failed to ensure ongoing communication and coordination of care with the dialysis center for a resident requiring dialysis services. The facility's policy on hemodialysis, dated June 3, 2024, mandates collaboration with the dialysis facility to meet the resident's needs and ensure safe administration of dialysis treatment. However, the facility did not maintain consistent communication with the dialysis center, as evidenced by incomplete or missing dialysis communication forms for Resident #64. The forms lacked post-dialysis vital signs, weight, medication administered, and fluid intake information for several dates in May and June 2024. Interviews with the Assistant Director of Nursing (ADON) and the RN Charge Nurse at the dialysis clinic revealed lapses in communication and documentation. The ADON acknowledged that the facility should have copies of the dialysis communication forms for each visit and that the charge nurse should monitor these forms for accuracy. The RN Charge Nurse at the dialysis clinic reported inconsistent receipt of communication forms from the facility and noted that other nursing homes routinely send forms with their residents. The RN Charge Nurse also highlighted the absence of documentation regarding communication with the facility about the resident's condition or any issues during treatment.
Significant Medication Error Due to Non-Adherence to Physician Orders
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the administration of antihypertensive medications despite contraindicated blood pressure readings. The facility's policy requires that medications be administered by licensed nurses or authorized staff according to physician orders and professional standards, including holding medications if vital signs fall outside prescribed parameters. However, the medical records revealed that a resident with severe cognitive impairment and a history of hypertension was given Metoprolol Tartrate and Amlodipine Besylate on two consecutive days, despite having a diastolic blood pressure reading below the physician's specified threshold of 60. The resident's medical records indicated a systolic blood pressure of 101 and a diastolic blood pressure of 55 on one of the days, with no blood pressure recorded on the following day. The Assistant Director of Nursing confirmed that the medications should have been withheld due to the low diastolic blood pressure. This oversight in medication administration represents a significant medication error, as the facility did not adhere to the physician's orders to hold the medications under these circumstances.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored appropriately, as evidenced by unsecured and unattended medications found in the rooms of two residents. Resident #3, who was admitted with diagnoses including Dementia and severe cognitive impairment, was observed with a bottle of mentholated ointment on her over-bed table. The facility's policy allows for self-administration of medication only after an interdisciplinary team assessment, which had determined that Resident #3 was not capable of safely self-administering or storing medications. Despite this, the mentholated ointment was found in her room on multiple occasions, and the Director of Nursing confirmed that it should not have been there. Similarly, Resident #65, who also had a diagnosis of Dementia and cognitive impairment, was observed accessing a drawer at the nursing station containing 26 packages of vitamin A & D ointment and a tube of phytoplex. The Certified Nursing Assistant confirmed that the resident should not have been going through the drawers containing chemicals. The Director of Nursing acknowledged that medications should not be stored unattended in the nursing station drawers, indicating a lapse in the facility's medication storage protocols.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain infection prevention practices for five of seven sampled residents who required enhanced barrier precautions. The facility's policy, dated June 18, 2024, mandates the use of enhanced barrier precautions for residents with wounds or indwelling medical devices to prevent the transmission of multidrug-resistant organisms. However, observations revealed that staff did not adhere to these precautions, as evidenced by the lack of personal protective equipment (PPE) usage during care activities for residents with pressure ulcers, indwelling urinary catheters, and gastrostomy tubes. Resident #9, with a diagnosis of a stage 4 pressure ulcer, did not have PPE available for enhanced barrier precautions during wound care performed by an LPN, who was unaware of the requirement. Similarly, Resident #39, who had an indwelling urinary catheter, was observed receiving a shower from an occupational therapist assistant without PPE usage. Resident #45, also with an indwelling urinary catheter, received catheter care from a CNA without PPE, and Resident #56, with a similar condition, was observed in the same situation. Additionally, Resident #319, who required enteral nutrition via a gastrostomy tube, had medications administered by an RN without PPE. Interviews with staff, including the Director of Nursing and Assistant Director of Nursing, revealed a lack of awareness and implementation of enhanced barrier precautions. The Assistant Director of Nursing acknowledged that enhanced barrier precautions were an addition to standard precautions and were recommended for residents with wounds, catheters, and indwelling medical devices. However, the facility had not yet implemented these precautions, despite initial education in April and plans to implement them in June. The Director of Nursing confirmed that no residents were on enhanced barrier precautions at the time of the survey.
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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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Nursing homes near Waverly
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waverly Hills Post Acute | 1.8 mi | ★★★★★ | 1 | 1 |
| Signature Healthcare Of Erin | 16.8 mi | ★★★★★ | 4 | 0 |
| Camden Healthcare & Rehab Center | 17.7 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Dickson | 23.1 mi | ★★★★★ | 4 | 0 |
| Dickson Health And Rehab | 23.1 mi | ★★★★★ | 0 | 0 |
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