Citations in Tennessee p

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain a clean and sanitary environment in multiple resident rooms and bathrooms, contrary to its own policies on routine bathroom cleaning and routine cleaning and disinfection. The facility’s policies, dated 6/2025, required providing a clean and sanitary environment, cleaning the entire toilet including the handle and underside of the flush rim with disinfectant and appropriate contact time, and reporting damaged items in need of repair. Observations conducted on several days showed that in one room, a motorized wheelchair had dried debris on the cushion, arms, and a large amount of multi-colored debris on the undercarriage. In another room, a wheelchair with a fabric heel protector cushion used as an armrest was spattered with small to pea-sized unknown multi-colored particles. Additional observations revealed that several resident bathrooms were not maintained in a sanitary condition. One bathroom had a trash can without a bag and with a dried brown substance on the outside, rim, and inside of the can, as well as a toilet seat with two areas of dried yellow residue and a yellow/orange substance around the base of the toilet. Other bathrooms in different rooms had yellow/orange or brown residue around or at the front base of the toilets. During an observation and interview in one of the bathrooms, the Administrator initially suggested the substance around the toilets might be related to the wax ring, but after wiping a small area with a wet wipe, the yellow/orange substance was easily removed, and the Administrator confirmed the area around the toilet was not clean.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with its own policies and accepted professional standards for three residents. The facility’s Fall Prevention Program policy, revised 10/01/2025, required that when any resident experiences a fall, staff must document all evaluations, assessments, and actions taken. For a resident with a history of falls, moderate cognitive impairment, and care plan problems including an ADL self-care performance deficit related to stroke and risk for falls, there was a documented fall on 10/3/2025 at 5:30 PM in a Fall Scene Investigation Report and an unwitnessed fall with head injury record. However, the DON stated that the medical record documentation for this resident was not accurate and did not reflect the fall event. The facility’s Medication Administration policy required staff to review the MAR to identify medications to be administered, remove medications from the source, administer them as ordered, and sign the MAR after administration. For a resident with COPD, diabetes mellitus, end stage renal disease, and dependence on hemodialysis, whose care plan included diabetes management and who was cognitively intact per MDS, multiple physician orders were not accurately or completely documented on the MAR. Lacosamide ordered to be given in the evening after hemodialysis on specific days showed no documentation of administration on one date. Levothyroxine ordered once daily had no documentation of administration on a morning dose. A sliding-scale insulin lispro order requiring blood glucose checks every six hours had no documented blood glucose levels at several scheduled times, and metoclopramide ordered before meals for nausea had no documentation of administration at multiple scheduled times. Another resident with type 1 diabetes mellitus with chronic kidney disease, history of stroke, and congestive heart failure, whose care plan also included diabetes management and who had moderate cognitive impairment per MDS, had a physician’s order for sliding-scale insulin lispro to be given three times a day on specified days. The MAR for this resident lacked documentation of the blood glucose level needed to determine the insulin dose at a scheduled time. During an interview, the DON confirmed that medications should be documented on the MAR when administered or withheld, including the reason for holding a medication, and acknowledged that blanks on the MAR for the two residents meant those scheduled medication doses were not documented, further supporting that the medical records were incomplete and inaccurate.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide continuous basic life support/CPR to a resident with a documented full code status who was found unresponsive in the bathroom. Facility policy required that any resident suffering cardiac or respiratory arrest receive CPR unless a valid DNR order was in place, and that basic life support be initiated and maintained until ambulance arrival. AHA BLS guidance similarly required immediate CPR when no breathing and no pulse are present, continuing until advanced life support personnel take over. The resident’s care plan and medical record showed he had elected full code status, had moderate cognitive impairment, used a wheelchair, and required assistance with transfers and ambulation. He had been treated for cirrhosis and hepatic encephalopathy and had a recent PRN order for Zofran for nausea, which was administered the evening before the event without documented effectiveness. On the morning of the incident, the resident’s roommate activated the call light after the resident had been in the bathroom for an extended period without sound. A CNA entered the room around 6:07 AM, found the resident on his knees slumped over the toilet and unresponsive, did not touch him, and immediately went to get the nurse. Video footage showed the LPN and two CNAs entering the room briefly and exiting after approximately 11 seconds, which the Regional Director later acknowledged was not enough time for a proper assessment. The LPN then left the room area and was at the nurses’ station when she first called 911, reporting that the resident was not breathing and that CNAs were performing CPR, although both CNAs later stated they did not perform CPR and did not see CPR performed by the nurse or EMS. The 911 operator instructed the LPN to go to the resident’s room and to call back from a cell phone so that the resident’s status could be directly assessed. During the second 911 call, the LPN reported that the resident was “gone,” that CPR had been stopped once he was pulled off the toilet, and confirmed that CPR was not being done. She described the resident as cold to touch, blue in the face, bleeding from the head, and without a pulse. Facility video showed that the crash cart did not arrive outside the resident’s room until about 6:20 AM, and there was no evidence that the AED on the crash cart was applied. EMS and fire personnel arrived within minutes and documented that the resident was dead without resuscitation efforts, with significant lividity and jaw rigor mortis, and pronounced him deceased at 6:30 AM. Interviews with the nurse practitioner, DON, and staff confirmed that for a full-code resident found without vital signs, CPR should be initiated and not discontinued prior to EMS arrival, and that in this case CPR was not initiated or continuously performed despite the resident’s full code status and absence of a DNR order. The surveyors concluded that the facility failed to provide continuous CPR as required, resulting in an Immediate Jeopardy citation at F-678.

Removal Plan

• Administrator and DON educated on BLS Standards, CPR Policy, and Facility Expectations during a Code Blue Response by the Regional Nurse

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an allegation of abuse to Adult Protective Services, the Long-Term Care Ombudsman, local law enforcement, and the state survey agency, and failed to complete the required 5-day follow-up report to the state agency. Facility policy on Abuse, Neglect and Exploitation, dated 6/2025, requires that all alleged violations be reported to the Administrator, state agency, APS, and all other required agencies within specified timeframes: immediately but no later than 2 hours if the allegation involves abuse or results in serious bodily injury, or within 24 hours if it does not. The policy also requires the Administrator to follow up with government agencies to confirm receipt of the initial report and to report the results of the investigation within 5 working days. Despite these requirements, there was no documentation that the allegation involving one resident was reported to any of the required external authorities or that a 5-day follow-up was completed. The resident involved was admitted with diagnoses including diabetes, hypertension, sepsis, and PTSD, and was documented as cognitively intact with a BIMS score of 13. On the night in question, the resident reported that a blonde CNA on night shift jerked her diaper off and slapped or tapped her inner thigh and arm during incontinence care, and later told a PTA that the CNA was mean to her, had slapped her leg and arm, and that she did not feel safe. The PTA immediately notified the Unit Manager, who in turn notified the Administrator and DON and initiated an internal investigation. The former DON confirmed awareness of the allegation and acknowledged that such allegations should be reported to the state, stating she thought the Administrator had reported it. The Administrator confirmed the allegation was not reported to the state agency and acknowledged that, under federal regulations, an allegation of abuse should have been reported within 2 hours of facility knowledge.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to employ a qualified full-time social worker as required by its own policy and federal regulations for a facility with more than 120 beds. The facility’s undated Social Services guidelines stated that a social worker would be employed on a full-time basis, yet a facility document signed by the Administrator on 2/12/2026 showed that from 5/9/2025 to 5/27/2025, 6/10/2025 to 8/11/2025, 10/8/2025 to 11/26/2025, and from 1/5/2026 to 2/12/2026, the facility did not employ a qualified social worker, totaling approximately 167 days (5.5 months) out of 9 months reviewed. During an interview, the individual currently functioning in the social worker role stated they began employment in October as a concierge and served in that role until early January, after which they were acting as the social worker despite having no social work degree or training and only “helping out with the social worker stuff” until a social worker could be hired. In a separate interview, the Administrator confirmed the periods during which the facility did not have a qualified social worker employed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure a safe environment and provide adequate supervision to prevent an elopement for a cognitively impaired resident with known wandering and exit-seeking behaviors. The resident had been admitted with multiple serious diagnoses, including traumatic subarachnoid hemorrhage, psychotic disorder, malnutrition, dysphasia, and a wedge compression fracture, and was assessed on the admission MDS as severely cognitively impaired with a BIMS score of 4. The admission assessment documented wandering behaviors on 1–3 days in the lookback period and a need for moderate assistance with ambulation. An elopement risk assessment completed on admission showed a score of 31, identifying the resident as at risk for elopement, with cognitive impairment, decreased safety awareness, judgment disturbances, a history/risk of wandering, and a history of one or two prior elopement events. Nursing documentation on 1/1/2026 described the resident as exit seeking several times after visitors left, stating he would leave when staff were not looking, and a physician’s order was obtained for a wander guard bracelet with every-shift checks for placement. Despite these findings, the resident’s care plan dated 12/18/2025 did not address wandering or exit-seeking behaviors prior to the elopement. The care plan at that time only referenced a behavior problem with general interventions such as speaking calmly, diverting attention, and removing the resident from situations as needed. The DON later acknowledged in interview that the resident had not been care planned for wandering or exit seeking before the incident and that he should have been. The facility’s elopement and wandering policy stated that residents at risk for elopement would receive adequate supervision, that interventions would be added to the care plan and communicated to staff, and that door locks/alarms and wander guard systems were in place but not a replacement for necessary supervision. However, there was no evidence that the resident’s identified elopement risk and exit-seeking behaviors were incorporated into a person-centered care plan or that specific interventions for wandering were implemented before the event. On the day of the incident, video footage showed the resident exiting the building through the front lobby without staff knowledge or assistance. The resident, wearing only a long-sleeved shirt, pants, and shoes, followed a visitor through the first set of doors, passed the receptionist, then followed the visitor through the second set of doors, walking past a housekeeper who was cleaning the lobby foyer. The resident then exited the front entrance and walked away from the facility along snow- and ice-covered walkways and roads in 21°F weather. The facility was not aware the resident had left until a family member called the receptionist to report that the resident was at a relative’s home, at which point a code white was initiated and a head count performed. Interviews and documentation indicated that the wander guard system at the front entrance did not alarm when the resident exited, and the Administrator later stated that the wander guard was not working properly at that time. The resident was ultimately found at a family member’s home after having fallen on an icy surface while exiting a private vehicle, and subsequent assessment and radiology confirmed an acute intertrochanteric fracture of the right hip. The facility’s failure to supervise the resident and to ensure that the elopement prevention systems and care planning were effectively implemented resulted in an Immediate Jeopardy citation at F689.

Removal Plan

• Completed a medical assessment for Resident #1 by the charge nurse and notified the Physician/Nurse Practitioner (NP) via the Assistant Director of Nursing.
• Administrator notified the physician and pain medications were administered as ordered by the charge nurse for Resident #1.
• Obtained an X-ray per physician orders for Resident #1; results showed an acute intertrochanteric right hip fracture; charge nurse notified Physician/NP and transferred Resident #1 to the hospital.
• Verified resident census and confirmed all residents present in the facility.
• Updated Elopement Risk Assessments for current residents to identify high elopement/wandering risk residents.
• Reviewed and revised care plans for all high elopement/wandering risk residents; updated interventions including wander guard placement for residents identified as high risk.
• Re-educated staff on the elopement/wandering policy, timely response to alarms, supervision expectations, and location of the Wander Guard Elopement Risk Binder; required completion prior to working.
• Revised maintenance procedures for auditing Wander Guard doors to include inspection of Wander Guard alarm panel integrity and hardware.
• Placed pictures and profiles for high-risk elopement residents with wander guard bracelets in the Elopement Risk Binder at the Reception Desk and at each nurses’ station.
• Provided 1:1 education to the housekeeper present at the door regarding recognizing wanderers/high elopement-risk residents and being observant in exit areas.
• Provided 1:1 education to the Maintenance department to check structural integrity of the wander guard door alarm system in addition to normal testing.
• Conducted elopement drills until all staff completed a drill and understood the process.
• Implemented Wander Guard alarm testing and door checks (including structural integrity) twice daily by Maintenance and/or Administrator; discussed results in QAPI and adjusted monitoring frequency based on audit results.
• Inspected the Wander Guard system; identified the front entrance panel as loose due to wear and tear; repaired immediately and tested the system as working correctly.
• Initiated enhanced monitoring at the reception area, including a Front Desk Visitor Screening Audit Log and Back Up Monitoring Log; educated Business Office Manager and Reception staff on these processes.
• Held an ad hoc QAPI meeting to review the incident, timeline, and immediate corrective actions with Medical Director participation.
• Implemented ongoing audits using the Wander Guard Door Alarm Audit and Front Desk Visitor Screening Audit Log.
• Completed vendor inspection and repair of the Wander Guard system by State Systems.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to timely disburse a resident refund in accordance with its admission agreement, which required that any credit balance be refunded within a reasonable time not to exceed 30 days after discharge or transfer, minus any outstanding private insurance balance. The admission and financial records showed that the responsible party was clearly identified on the admission documents, face sheet, and financial records, and was authorized for healthcare decision making, care plan participation, emergency contact status, healthcare representative status, and management of the resident’s financial liabilities. The responsible party was also an authorized party on the resident’s private bank accounts used to pay the resident’s monthly private pay liability to the facility. The resident, who had diagnoses including unspecified cerebral infarction (stroke), chronic CHF, and metabolic encephalopathy, was admitted on the specified date and later died of natural causes at the facility. At the time of death, the business office and resident account records showed that $1,995.00 was owed to the responsible party to settle the account. The facility did not disburse these funds until after it received a notarized Heirship Affidavit from the local court and then further delayed issuing the refund check for 41 days after receipt of that document, resulting in the refund being paid more than five months after the resident’s death. During interview, the Administrator confirmed that, under the admission agreement, the refund should have been issued within 30 days of the resident’s death and that the agreement had not been followed by the former administration.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to follow established clinical guidelines regarding the use of latex-containing urinary catheters in a resident with a documented latex allergy. Clinical standards from an online professional journal on urology and continence care state that PTFE (a type of silicone) coated catheters are latex catheters and must be avoided in patients with known latex allergy or sensitivity due to ongoing risk of latex reaction. The facility’s medical storeroom stocked both PTFE silicone-coated latex catheters and 100% silicone, latex-free catheters intended for residents with latex sensitivity or allergies. The resident involved was admitted with multiple diagnoses including paraplegia, cervical spinal stenosis, post-laminectomy syndrome, flaccid neuropathic bladder, UTI, and anxiety disorder, and required use of a latex-free indwelling urinary catheter for urinary elimination. The resident’s MDS showed a BIMS score of 15, indicating intact cognition, and the MAR/TAR documented latex as an allergy. Despite this, a nurse’s note documented that on 8/6/2025 the resident’s leaking Foley catheter with sediment was replaced using sterile technique with a new catheter from facility stock, and there is no indication in the note that a latex-free catheter was selected, even though the resident had a known latex allergy. Subsequently, the resident reported concerns about having a latex Foley catheter in place and requested transfer to the hospital, stating she did not want to return to the facility. Hospital records documented that the resident reported a latex catheter had been inserted four days earlier despite her latex allergy and that she was experiencing burning and itching and felt she was having a reaction. In the ED, the urinary catheter was replaced with a non-latex catheter. During interview, the DON confirmed that, based on review of hospital and facility documentation, a stock silicone-coated latex catheter had been inserted for this resident in error, and that the facility failed to follow recognized standards of care related to the use of latex-containing devices in persons with known latex sensitivity.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to follow physician orders for IV antibiotic therapy for one resident admitted with a UTI, urinary retention, Enterococcus faecalis bacteremia, and presumptive infective endocarditis. Hospital discharge documentation and an infectious disease (ID) physician note specified that the resident was to receive ampicillin 2 g IV every 4 hours through a specified January stop date, representing six weeks of therapy after the first negative blood cultures. These written hospital orders, present in the resident’s physical chart, clearly directed continuation of IV ampicillin at that dose and frequency until mid-January. On admission, the Admission Nurse entered the ampicillin order into the facility’s computer system with an incorrect stop date in December instead of the January stop date ordered by the ID physician. The electronic order was entered to run from the admission date with an end date in mid-December, and this incorrect order was confirmed by the RN Charge Nurse later that same day. The comprehensive care plan for antibiotic therapy also reflected the incorrect December stop date. As a result, the Medication Administration Record (MAR) shows that the resident received ampicillin IV every four hours only from the evening of admission through mid-December, at which point the medication was stopped per the erroneous end date. Because of the incorrect stop date and failure to reconcile the electronic order with the hospital discharge and ID orders, the resident did not receive ampicillin from mid-December until the medication was later resumed in late December, resulting in 59 missed doses of IV ampicillin. A Medication Occurrence Report documented this as an omitted dosage error caused by an admission order error and chart check error, noting that the infectious disease orders in the chart had the correct January stop date while the electronic order had the wrong December stop date. The DON confirmed that the Admission Nurse, the RN Charge Nurse, and the pharmacy consultant did not identify the discrepancy at the time of admission, and that the resident’s ampicillin was discontinued earlier than ordered, leading to the lapse in therapy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves a failure of the facility’s pharmaceutical services, including both the contracted pharmacy provider and the consultant pharmacist, to identify a transcription error in an IV antibiotic order, resulting in an incorrect stop date and an extended omission of ordered doses. A resident was admitted with diagnoses including UTI, urinary retention, and Enterococcus faecalis bacteremia, and had hospital infectious disease orders for Ampicillin 2 g IV every 4 hours to continue through a specified date in January. The hospital discharge summary and infectious disease note documented Ampicillin 2 g IV every 4 hours with a stop date of January 13. The facility faxed the admission orders to the pharmacy provider, and the order was entered into the facility’s electronic system (PCC) on the day of admission as Ampicillin Sodium Solution 2 g IV every 4 hours, but with an incorrect stop date of December 13 instead of January 13. The order was confirmed in the system later that same day. According to facility policy, the consultant pharmacist is responsible for providing consultation on all aspects of pharmacy services, including helping the facility develop processes for receiving and transcribing medication orders, and for performing a Medication Regimen Review (MRR) for every resident upon admission and at least monthly. The MRR is to include a thorough review of the medical record to prevent, identify, report, and resolve medication-related problems and errors, including omissions of ordered medications and documentation-related errors. The pharmaceutical services agreement with the pharmacy provider also requires that a licensed pharmacist review each resident’s drug regimen, including the medical chart, and report any irregularities to the attending physician, medical director, and DON. The agreement further states that the pharmacy will use an electronic system (PCC) to manage orders and MARs and that the pharmacy’s medical records department is responsible for ensuring that faxed orders match what is entered into PCC. Despite these requirements, multiple review processes failed to detect the incorrect stop date. The pharmacy provider received the faxed admission orders on the day of admission, which correctly showed Ampicillin 2 g IV every 4 hours with a stop date of January 13, but the facility-entered order in PCC reflected a stop date of December 13. A pharmacist from the pharmacy provider performed a Drug Regimen Review on the day of admission and documented that the medications were reviewed with no recommendations. The consultant pharmacist completed an admission Pharmacy Drug Regimen Review three days later and also documented no recommendations or irregularities. The consultant pharmacist later stated that she reviews new admission medications to ensure physician orders match what is entered in PCC and that stop dates are part of this review, and acknowledged she should have identified an incorrect stop date. The pharmacy provider’s Director of Operations confirmed that the medical records department’s verification, completed three days after admission, should have identified the discrepancy between the faxed order’s January stop date and the December stop date entered in PCC but did not. As a result, the MAR shows the resident received Ampicillin IV every four hours from the evening of admission through December 13, when the medication stopped per the incorrect stop date, and the resident then missed 59 doses between December 13 and December 24, when the error was finally identified and the medication was resumed. Interviews further clarified the sequence of events and the roles of involved staff. The DON stated that the admissions nurse entered the Ampicillin order with the incorrect December stop date, causing the medication to stop in error on that date. The DON confirmed that the error was not identified until December 24, at which time an order was obtained to resume the medication, and that the resident missed doses every four hours during the gap period. The Medication Occurrence Report documented the error as an omitted dosage due to an admission order error and chart check error, specifying that the wrong stop date was entered on admission and that infectious disease orders present in the record had the correct January stop date. The pharmacy provider’s Director of Operations confirmed that the faxed order to the pharmacy showed the correct January stop date, that the facility had entered a December stop date into PCC, and that the pharmacy’s medical records verification process should have detected and reported this discrepancy but did not. These combined failures by the facility’s pharmacy services and consultant pharmacist to identify and correct the transcription discrepancy led to the prolonged interruption of the resident’s ordered IV antibiotic therapy.