Citations in Tennessee
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Tennessee.
Statistics for Tennessee (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Tennessee
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 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.
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 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.
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 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.
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 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.
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