Creekview Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Knoxville, Tennessee.
- Location
- 3300 Broadway Ne, Knoxville, Tennessee 37917
- CMS Provider Number
- 445297
- Inspections on file
- 16
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Creekview Health And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found multiple food safety and storage deficiencies, including dietary staff with visible facial hair working in the kitchen without required beard restraints, unlabeled dry cereal and meat packages lacking names and dates, and a walk-in freezer operating at a temperature that left numerous food items not frozen solid while still available for use. Additionally, a half-full carton of nutritional supplement with a past expiration date was found on a medication cart and confirmed by an LPN to be expired yet still available for resident use. No residents were reported to have signs of foodborne illness at the time of the survey.
A resident with Parkinsonism, spastic quadriplegic cerebral palsy, dementia, and moderate cognitive impairment required total assistance with eating per the care plan. During a lunch meal, a CNA was observed standing over the resident while providing feeding assistance. The DON confirmed that this manner of assistance did not promote dignity, resulting in a failure to honor the resident’s right to be treated with dignity and respect during ADL care.
The facility failed to update the PASRR for a resident whose pre-admission Level I screen listed only an anxiety disorder and psychotropic use, while the admission record and subsequent MDS and care plan documented additional mental health diagnoses including PTSD, schizoaffective disorder, and schizophrenia, along with severe cognitive impairment. Despite facility policy requiring PASRR resident review when there is a change in condition that may trigger a new evaluation, the PASRR was not resubmitted to reflect these diagnoses, as confirmed by the admissions LPN and the DON.
A resident with a Stage 4 sacral pressure ulcer, chronic Hepatitis C, and a urogenital herpes infection was placed on transmission-based precautions per physician orders due to copious wound drainage and viral hepatitis, and staff implemented these precautions with appropriate signage and PPE at the room. However, review of the comprehensive care plan showed it only addressed pressure ulcers with enhanced barrier precautions and did not include the ordered transmission-based precautions, contrary to facility policy requiring comprehensive person-centered care plans. The IP and DON both confirmed that the resident was on transmission-based precautions and that these precautions were not incorporated into the resident’s care plan.
Surveyors found that opened insulin pens and an ophthalmic solution on a medication cart were not labeled with open dates as required by manufacturer guidelines and facility policy. One resident with Type 2 DM, chronic pain syndrome, and HTN had an opened Tresiba FlexTouch pen at room temperature labeled only with a 56-day discard instruction but no open date. Another resident with Type 2 DM, COPD, and HTN had an opened NovoLog pen at room temperature labeled only with a 28-day discard instruction and no open date. A third resident with glaucoma, major depressive disorder, and HTN had an opened latanoprost eye drop bottle labeled with a 42-day discard instruction but no open date. An LPN and the DON confirmed that these medications were not stored and labeled properly.
Staff failed to follow infection control practices during wound care for a resident with COPD, dementia, hypertension, and a stage 4 pressure ulcer who was receiving hospice services and had severe cognitive impairment per MDS. Facility policy required removal of soiled dressings by pulling the glove over the dressing, discarding it, sanitizing hands, and donning new gloves before continuing care. During an observed wound treatment to the sacral area, a Wound Care Nurse donned gloves and a gown, removed a soiled dressing, and then cleansed the wound without changing gloves or sanitizing hands. In interviews, the nurse acknowledged not removing gloves or sanitizing hands after removing the soiled dressing, and the DON confirmed that infection control practices were not followed.
Food Safety, Labeling, and Storage Deficiencies in Dietary and Medication Areas
Penalty
Summary
Surveyors identified that dietary staff did not follow the facility’s sanitary standards and food safety policies. Two dietary aides with visible facial hair were observed working in the kitchen without required beard restraints, despite the policy stating that hair and beard restraints must be worn at all times in the kitchen. In the dry food storage area, a 6-quart clear plastic container holding about one-third full of dry cereal was found without any label identifying the food item and without an open date, discard date, or expiration date, contrary to the facility’s food storage policy requiring foods to be labeled and dated. In the walk-in refrigerator, 14 packages of meat were stored without labels identifying the type of meat and without expiration dates. Further observations in the walk-in freezer showed the thermometer reading 30 degrees, and multiple frozen food items, including salisbury steaks, pork chops, sweet potato puffs, cinnamon rolls, pork patties, chicken tenders, ice cream cups, pork franks, smile fry potatoes, and hamburger patties, were not frozen solid, despite the facility’s policy that foods must be stored at a temperature that keeps them frozen solid. These items were confirmed to be available for resident use and should have been discarded per the CDM. Additionally, on a medication cart, a 32-ounce carton of nutritional supplement that was half full was found with an expiration date that had already passed, and an LPN confirmed the supplement was expired and still available for resident use. The Infection Preventionist reported that no residents had shown signs of foodborne illness at the time of the survey.
Failure to Promote Dignity During Assisted Feeding
Penalty
Summary
The facility failed to ensure a resident was treated with dignity during feeding assistance. The facility’s undated Resident Rights policy stated that residents have the right to be treated with dignity and respect in a manner that promotes or enhances quality of life. Resident #19 was admitted with diagnoses including Parkinsonism, spastic quadriplegic cerebral palsy, and dementia, and a quarterly MDS assessment showed a BIMS score of 12, indicating moderate cognitive impairment. The resident’s comprehensive care plan, revised 6/30/2025, documented an ADL self-care performance deficit related to cerebral palsy and Parkinson’s disease and indicated the resident required total assistance with eating. During an observation on 9/28/2025 at 12:47 PM, CNA B was seen standing over Resident #19 while assisting with the lunch meal, and during an interview at 12:56 PM, the DON confirmed that CNA B failed to promote dignity for the resident by standing over the resident during feeding assistance. This conduct constituted a failure to honor the resident’s right to be treated with dignity and respect and to receive assistance with eating in a manner consistent with the facility’s Resident Rights policy and the resident’s assessed needs.
Failure to Update PASRR for Resident With Additional Mental Health Diagnoses
Penalty
Summary
The facility failed to resubmit a Pre-admission Screening and Resident Review (PASRR) for a resident who was admitted with additional mental health diagnoses not reflected on the original PASRR. Facility policy stated that the PASRR process applies to all admissions, particularly for individuals with serious mental illness, intellectual disability, or related conditions, and that a resident review is to be conducted when there is a change in the resident's condition that may trigger a new PASRR evaluation. The resident’s Level I PASRR screen, completed prior to admission, documented an anxiety disorder and use of Buspar 10 mg daily, but did not include diagnoses of PTSD or schizoaffective disorder. The medical record showed that upon admission the resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction, schizoaffective disorder, anxiety disorder, and PTSD. A subsequent quarterly MDS assessment documented severe cognitive impairment with a BIMS score of 5 and active diagnoses of anxiety disorder, schizophrenia, and PTSD. The comprehensive care plan further identified antidepressant use related to depression and schizoaffective disorder, antipsychotic use related to schizophrenia, risk for re-traumatization related to PTSD, and potential mood problems related to depression, anxiety, and schizoaffective disorder. During interviews, the Admissions/LPN Nurse Case Manager and the DON confirmed that a new PASRR to include PTSD and schizoaffective disorder was not submitted after the resident’s admission.
Failure to Include Transmission-Based Precautions in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan that included transmission-based precautions for one resident. Facility policy dated 12/2023 required development of a comprehensive person-centered care plan for each resident with all information necessary to properly care for them. The resident was admitted with diagnoses including a Stage 4 sacral pressure ulcer, chronic Hepatitis C, and a herpes viral infection of the urogenital system. An admission MDS showed the resident was cognitively intact and documented the presence of a pressure ulcer and viral hepatitis. Physician orders dated 9/26/2025 placed the resident on transmission-based precautions for a wound organism, and an order dated 9/27/2025 directed staff to paint lesions on the inner vulva with betadine daily. Review of the comprehensive care plan dated 7/15/2025 showed the resident was care planned for pressure ulcers with enhanced barrier precautions, but there was no care plan addressing the ordered transmission-based precautions. Observations on 9/28/2025 confirmed that transmission-based precautions were in place at the resident’s room, with appropriate signage and PPE available at the door. In an interview, the Infection Preventionist confirmed the resident was on transmission-based precautions due to copious wound drainage and a diagnosis of viral Hepatitis C. In a separate interview, the DON confirmed that the resident’s care plan had not been developed to include transmission-based precautions, despite the existing orders and implemented precautions.
Failure to Properly Label Opened Insulin Pens and Ophthalmic Drops
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were labeled in accordance with professional standards and the facility’s own Medication Labeling and Storage policy, which states that nursing staff are responsible for maintaining medication storage in a safe manner and ensuring medications are labeled accordingly. Manufacturer guidelines for Tresiba (insulin degludec) FlexTouch pens require opened pens stored at room temperature to be discarded after 56 days, NovoLog (insulin aspart) pens after 28 days, and Xalatan (latanoprost) ophthalmic solution after 6 weeks at room temperature. Residents involved included one with Type 2 diabetes, chronic pain syndrome, and hypertension; another with Type 2 diabetes, COPD, and hypertension; and a third with unspecified glaucoma, major depressive disorder, and hypertension, each with active physician orders for these medications. During an observation of a medication cart, surveyors found an opened Tresiba FlexTouch insulin pen for one resident stored at room temperature without an open date, bearing only a label instructing discard after 56 days. They also observed an opened NovoLog insulin pen for another resident at room temperature without an open date, labeled only to discard after 28 days. Additionally, an opened 2.5 mL bottle of latanoprost ophthalmic solution for a third resident was found undated, with a label to discard after 42 days. Both an LPN and the DON confirmed that these medications were not stored properly for the three residents, specifically acknowledging the lack of appropriate labeling with open dates as required.
Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
Facility staff failed to follow infection prevention and control guidelines during wound care for one resident. The facility’s wound care policy directed staff to put on exam gloves, remove the dressing, pull the glove over the dressing and discard, sanitize hands, and then put on new gloves. Resident #44 was admitted with diagnoses including COPD, dementia, and hypertension, had a physician’s order to cleanse a sacral wound with normal saline, apply calcium alginate and collagen particles, and cover with a foam dressing three times per week and as needed, and had a comprehensive care plan noting hospice services, potential for further pressure ulcer development, and a stage 4 pressure ulcer. The resident’s MDS showed a BIMS score of 00, indicating severe cognitive impairment. During an observed wound care procedure in the resident’s room, the Wound Care Nurse donned gloves and a gown, removed a soiled dressing, and then, without changing gloves or sanitizing hands, proceeded to cleanse the resident’s wounds. In subsequent interviews, the Wound Care Nurse confirmed he failed to remove gloves or sanitize his hands after removing the soiled dressing, and the DON confirmed that the nurse did not follow infection control practices during this wound care.
Latest citations in Tennessee
Electronic Medical Records Left Visible on Unattended Computers: Two residents' EMRs were left open and visible on unattended computers during wound care and med pass. One resident had HTN, DM, and malnutrition with moderate cognitive impairment, and another resident had acute respiratory failure with hypoxia, HTN, DM2, and Afib with intact cognition. Staff confirmed the screens were left open and available for public view.
Medication cart security was not maintained for Cart 700. Facility policy required the cart to be locked when out of the medication nurse’s sight, but an RN walked away from the cart and later entered a resident room while leaving it unlocked and unattended. The RN confirmed the cart should have been locked, and the President of Clinical Operations confirmed carts should be locked when unattended.
Staff failed to follow diabetes management policies and provider orders for multiple residents by not consistently notifying the MD/NP of blood glucose (BG) readings outside ordered and policy-defined parameters and not documenting required treatment for hypoglycemia. One resident with Type 2 DM, severe cognitive impairment, and a high A1C had repeated episodes of severe hyperglycemia and hypoglycemia over several months, with numerous BG values above 400–500 mg/dL and below 70 mg/dL that were neither reported to the provider nor accompanied by documented administration of Glutose or glucagon. This resident later experienced altered mental status, hypotension, and a BG of 600 mg/dL, was transferred to the ED with a BG of 1025 mg/dL and diagnosed with DKA and related complications, and subsequently had a large acute to subacute cerebral infarct. Another resident on Lantus and Humalog sliding-scale insulin had multiple high and low BG readings, including values in the 40s and 50s mg/dL, without consistent documentation of hypoglycemia treatment or provider notification when thresholds were met. Similar unreported abnormal BG readings were found in other residents, leading surveyors to cite noncompliance with F684 for failure to provide appropriate treatment and care according to orders and resident needs.
The facility failed to report an allegation of staff-to-resident physical and verbal abuse to the state survey agency within the required two-hour timeframe. A resident with severe dementia, muscle weakness, and difficulty walking, who required two-person assistance for ADLs, became combative during perineal care, and multiple CNAs later reported that a CNA had roughly grabbed the resident’s arms, slammed the resident’s wrists onto the chest, used profanity, made threats, and stated the resident belonged in a psychiatric ward. These CNAs did not report their concerns immediately, and the allegation was not submitted to the state reporting agency until two days after the incident, contrary to facility policy and the expectations stated by the DON and ADM.
A resident with COPD, lack of coordination, and anxiety disorder had a prior fall with a care plan intervention for nonskid strips at the bedside. The facility later failed to keep that intervention in place, and the resident was found on the floor beside the bed after hollering for help, resulting in a left hip fracture and surgical repair. Surveyors observed the nonskid strips were not at the bedside, and the DON, ADM, LPN, and RD confirmed they were missing.
Resident Trust Funds Exceeded Medicaid Asset Limit: The facility failed to keep resident trust fund balances under the $2,000 Medicaid asset limit for multiple residents. Record review showed several residents with diagnoses including dementia, CHF, CKD, diabetes, hemiplegia, bipolar disorder, Parkinson’s disease, and traumatic subdural hemorrhage had trust fund balances ranging from $2,769.53 to $9,020.33, and both the BOM and Administrator stated the limit was under $2,000.
Unsecured and unlabeled medications were found at a resident’s bedside and in a medication cart. A resident with multiple diagnoses, including HTN and delusional disorder, had several scheduled oral meds left unattended in a clear cup on the nightstand without a self-administration order or assessment, and an LPN identified the pills as the resident’s medications. In a separate observation, an LPN and the DON found prepared, unlabeled meds left in a med cart drawer instead of being administered or otherwise secured.
A resident with dementia, seizure disorder, repeated falls, and high fall risk was care-planned for a low bed with brakes locked, a fall mat, and call light within reach, and was totally dependent on staff for transfers and bed positioning. Despite this, staff accounts indicated the bed was often kept at about waist height, and several staff reported not seeing a fall mat at the bedside. The resident was later found supine on the floor with her head and torso under the bed, the bed frame resting on her chest and head, and the corded bed remote under her back, requiring staff to raise the bed to remove her. A detective observed that a fall alert device on the bed was not plugged in and that the call light was tucked behind the nightstand, out of the resident’s reach, though it worked when tested. EMS and police documented compression marks on the resident’s torso and face consistent with the bed frame and piston. The facility’s own safety policy required implementation of interventions to reduce accident risks, but records showed no care-plan revision with additional bed-related safety measures after prior falls and no documentation that existing interventions were consistently implemented, leading surveyors to cite a deficiency for failure to prevent accidents and maintain a hazard-free environment.
A cognitively intact resident with chronic kidney disease, hypertension, and type 2 DM was struck on two occasions by another resident with severe cognitive impairment and aphasia who entered the resident’s room and hit her after being asked to leave. After the first incident, the care plan was revised to include a stop sign on the door, but staff failed to consistently maintain this intervention, including not reattaching it after an appointment and forgetting to put it back up after exiting the room. Surveyors later observed the stop sign missing and no staff in sight while the resident sat on the bed, and the resident reported that the other resident had entered her room and struck her twice and that staff did not keep the stop sign up much. Skin assessments documented transient redness but no lasting injury, and the DON confirmed that physical contact occurred on both occasions.
A resident with chronic kidney disease, essential hypertension, and type 2 DM, who was cognitively intact per MDS/BIMS, had a comprehensive care plan that required a stop sign to be maintained on the room door, with staff assistance as needed to keep it in place. During observation, the stop sign was not on the door, no staff were in sight while the resident sat on the side of the bed, and the resident reported that staff did not keep the stop sign up much anymore. An LPN admitted forgetting to replace the stop sign after leaving the room, and the DON confirmed that the care plan intervention requiring the door stop sign was not followed.
Electronic Medical Records Left Visible on Unattended Computers
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when electronic medical records were left open and visible to others. Facility policy stated resident health information must remain private and that the MAR must remain closed or covered when not in direct use. Resident #76, who was admitted with diagnoses including hypertension, diabetes, and malnutrition and had a BIMS score of 8 indicating moderate impairment, was observed on 5/11/2026 at 2:37 PM with the wound care cart unattended and the computer on top of the cart open to the resident's electronic medical record and available for public view. The wound care nurse later returned and confirmed the screen had been left open to Resident #76's record. Resident #41, who was admitted with diagnoses including acute respiratory failure with hypoxia, essential hypertension, type 2 diabetes mellitus, and paroxysmal atrial fibrillation and had a BIMS score of 13 indicating cognitive intactness, was observed during medication administration on Cart 700 on 5/12/2026 at 7:40 AM when RN A walked away from the medication cart leaving the computer open and the resident's electronic medical record available for public view. A later observation at 8:01 AM showed RN A entering a room while the computer remained open with Resident #41's electronic medical information still visible. RN A confirmed the screen was open and available for public view, and the President of Clinical Operations later confirmed the electronic medical record should not be unattended and left open for public view.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure medications were securely stored in 1 medication cart, Cart 700, out of 3 medication carts reviewed. The facility policy titled, Medication Administration General Guidelines, dated 9/18, stated that during medication administration, the medication cart is to be kept closed and locked when out of sight of the medication nurse. During observation on 5/12/2026 at 7:40 AM, RN A walked away from Cart 700, leaving the cart unlocked and unattended. During another observation on 5/12/2026 at 8:01 AM, RN A entered room [ROOM NUMBER] and again left the medication cart unlocked and unattended. RN A later confirmed she should have locked the medication cart when it was left unattended, and the [NAME] President of Clinical Operations confirmed the medication carts should be locked when left unattended.
Failure to Follow Diabetes Management Policies and Notify Provider of Abnormal Blood Glucose Levels
Penalty
Summary
The deficiency involves the facility’s failure to follow its own diabetes management policies and physician/NP orders for monitoring and responding to abnormal blood glucose (BG) levels, including required provider notification and treatment for hypoglycemia and hyperglycemia. Facility policies defined hypoglycemia as BG <70 mg/dL and required immediate provider notification and administration of rapidly absorbed glucose or glucagon, and defined thresholds for hyperglycemia that required provider contact when BG values were >250 mg/dL more than once in 24 hours or >300 mg/dL more than once over two consecutive days. For residents with sliding-scale insulin orders, the MARs also contained explicit instructions to notify the physician or NP when BG readings exceeded specified ranges (e.g., >351–400 mg/dL and above). Despite these clear parameters, staff repeatedly failed to notify the provider or document required treatment when BG readings fell outside ordered or policy-defined ranges. Resident #1, who had Type 2 diabetes, acute kidney failure, depression, anxiety disorder, and a severely impaired BIMS score of 3, had an A1C of 9.2% in November 2025 and was on a consistent carbohydrate diet with dysphagia modifications and sliding-scale insulin lispro before meals. Throughout January, February, March, and April 2026, Resident #1’s Weights and Vitals Summary reports showed numerous episodes of severe hyperglycemia (often >400–500 mg/dL and above the sliding-scale notification thresholds) and multiple episodes of hypoglycemia with BG values as low as 42–54 mg/dL. On multiple dates, there was no documentation that Glutose or glucagon was administered for BG <70 mg/dL, and there was no evidence that the physician or NP was notified when BG values exceeded the facility’s policy thresholds or the sliding-scale notification parameters. The record also showed that after the sliding-scale insulin order was discontinued, staff still did not consistently notify the provider when BG values met the facility’s policy criteria for reporting. Resident #1 subsequently experienced clinical deterioration associated with very high BG levels. A progress note on 3/16/2026 documented altered mental status, functional decline, unresponsiveness, hypotension (BP 83/42), tachycardia, and a BG of 600 mg/dL, leading to transfer to the ED. Hospital records indicated presentation with gradually worsening condition over 2–3 days, hypoxia requiring oxygen, and a BG of 1025 mg/dL, with diagnoses including diabetic ketoacidosis (DKA), acute kidney injury, UTI, acute toxic metabolic encephalopathy, and hypotension, and treatment with an insulin drip in the ICU. After return to the facility, Resident #1 continued to have unreported hypoglycemic readings (e.g., 67–69 mg/dL with no documented Glutose or glucagon) and further episodes of severe hyperglycemia that met policy thresholds for provider notification but were not reported. Later in March, the resident was again sent to the hospital with left-sided weakness and facial droop, and imaging showed a large acute to subacute infarct involving the right parietal and occipital lobes. Other sampled residents also had unreported abnormal BG readings. Resident #2, with orders for Lantus and Humalog sliding-scale insulin, had multiple hyperglycemic readings above the sliding-scale notification thresholds (e.g., 376–478 mg/dL) and several hypoglycemic episodes with BG values between 43–54 mg/dL. On several of these occasions, there was no documentation that Glutose or glucagon was administered, and no evidence that the physician or NP was notified when BG values met either the sliding-scale notification parameters or the facility’s policy thresholds. For at least one hypoglycemic episode (BG 43 mg/dL), medication treatment was documented, but other low readings lacked such documentation. Similar patterns of unreported abnormal BG values and lack of documented hypoglycemia treatment were identified for additional residents reviewed for medication administration, contributing to the finding that the facility failed to ensure appropriate treatment and provider notification for out-of-parameter BG readings. Surveyors determined that the facility’s failure to ensure Resident #1 received care and services to maintain BG levels within a safe range, and to follow policies and orders for provider notification and hypoglycemia management, resulted in Immediate Jeopardy at F684. The Immediate Jeopardy period was identified as beginning on 1/1/2026 and was later removed, but noncompliance at F684 continued at a lower scope and severity for ongoing monitoring of the effectiveness of corrective actions.
Failure to Timely Report Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical and verbal abuse to the state survey agency within the required two-hour timeframe. Facility policy required any partner with direct or indirect knowledge of events that might constitute abuse, neglect, misappropriation of patient property, or exploitation to report immediately, but not later than two hours if the events involved abuse or resulted in serious bodily injury, and not later than 24 hours if they did not. Resident #89, admitted with severe dementia with agitation, muscle weakness, and difficulty walking, required assistance of two staff for ADLs. A Facility Reported Incident form documented that on 01/12/2026 at 12:00 PM, the resident became combative during perineal care and witnesses observed CNA #4 strike and pinch the resident several times, hold the resident by the wrists, make threatening comments, and use inappropriate language. However, this allegation was not submitted to the state reporting agency until 01/14/2026 at 2:57 PM. Witness statements from CNAs #3, #5, and #6 described multiple episodes of rough and aggressive behavior by CNA #4 toward Resident #89 during care on 01/12/2026 and 01/13/2026, including roughly taking the resident’s arms, cursing at the resident, slamming the resident’s wrists onto the chest, making threats, and telling the resident they belonged in a psychiatric ward while pushing the resident’s arms into the chest. The DON stated that on 01/14/2026 these CNAs reported the allegations of abuse from the prior dates, and confirmed that her expectation was that allegations of abuse be reported immediately. The Administrator similarly stated that staff were expected to report allegations of abuse immediately and no later than two hours from when the abuse occurred, and that the facility had two hours to report the allegation to the state reporting agency. He acknowledged that CNAs #3, #5, and #6 did not report the allegations in a timely manner, resulting in the late reporting of the abuse allegation to the state survey agency.
Failure to Implement Fall Intervention After Prior Fall
Penalty
Summary
The facility failed to implement a fall-related care plan intervention for Resident #7 after a fall on 5/15/2025. The resident was admitted with diagnoses including COPD, lack of coordination, and anxiety disorder, and a quarterly MDS assessment indicated a BIMS score of 15, showing the resident was cognitively intact and independent with all aspects of care. After the 5/15/2025 fall, nursing documentation stated the resident was found sitting on the floor after trying to get to the bathroom and slipping, and the incident report identified the root cause as footwear, with a new intervention of nonskid strips to the exiting side of the bed. The comprehensive care plan dated 5/15/2025 included the intervention of nonskid strips to the bedside. However, the facility later failed to have those nonskid strips in place. On 4/12/2026, Resident #7 was again found on the floor beside the bed after hollering for help, and the incident report and nursing note documented the fall. A radiology report from that date showed a left intertrochanteric fracture, and an operative note dated 4/15/2026 documented internal fixation of the left hip. During observations on 4/21/2026, surveyors found no nonskid strips at the bedside, and both the LPN and DON confirmed they were not in place. The DON acknowledged the resident had fallen on 5/15/2025 and that nonskid strips had been the intervention, but they were not present at the time of the later fall. The ADM also confirmed the strips were not in place, and the RD stated they were placed only after the facility was informed on 4/21/2026 that they were missing.
Resident Trust Funds Exceeded Medicaid Asset Limit
Penalty
Summary
The facility failed to maintain resident trust fund balances under the $2,000 Medicaid asset limit for 10 of 111 sampled residents. Review of the American Council on Aging website showed that in 2026, a single Medicaid nursing home applicant in Tennessee must have assets under $2,000. Medical record and trust fund statement reviews showed multiple residents had balances above that limit, including residents with diagnoses such as atrial fibrillation, dementia, depression, dysphagia, anxiety, hemiplegia, heart failure, diabetes, chronic kidney disease, anemia, bipolar disorder, chronic respiratory failure, Parkinson’s disease, traumatic subdural hemorrhage, malnutrition, and hypertension. Resident trust fund statements dated 4/22/2026 showed balances of $4,945.96 for Resident #11, $7,764.26 for Resident #16, $3,324.09 for Resident #38, $2,950.01 for Resident #86, $5,350.97 for Resident #92, $3,874.46 for Resident #101, $3,931.97 for Resident #110, $2,769.53 for Resident #119, $5,911.60 for Resident #128, and $9,020.33 for Resident #177, all above the $2,000 limit. During interview, the BOM stated the resident trust account limit was $2,000.00, and the Administrator also stated resident trust accounts should be under $2,000.00.
Unsecured and Unlabeled Medications Found at Bedside and in Medication Cart
Penalty
Summary
Medications and biologicals were not properly stored in accordance with facility policy and accepted professional principles when medications were left unattended and unlabeled at a resident’s bedside and when prepared medications were left unsecured and unlabeled in a medication cart. The facility policy stated medications and biologicals are to be stored safely, securely, and properly, with access limited to authorized staff, and that all medications dispensed by the pharmacy are to be stored in the container with the pharmacy label. The self-administration policy required a physician order and interdisciplinary assessment before a resident could self-administer medications, along with a quarterly skill assessment as needed. Resident #41 was admitted with diagnoses including Autistic Disorder, Gilbert Syndrome, Delusional Disorders, Hypertension, Edema, Protein-Calorie Malnutrition, and Peripheral Vascular Disease. The physician ordered multiple 9:00 AM oral medications, but there was no physician order for self-administration and the resident was not assessed or care planned for self-administration, despite a BIMS score of 13 indicating cognitive intactness. During observation, 3 white tablets, 2 orange tablets, 2 light blue and yellow capsules, and 1 white half tablet were found in a clear cup on the resident’s nightstand unattended and unlabeled, and an LPN identified them as the resident’s scheduled medications. In a separate observation, a medication cart contained unsecured and unlabeled medication cups with tablets and a capsule in the drawers, and the DON stated medications that were prepared and unable to be administered should be wasted and not stored in the med cart.
Failure to Maintain Bed Safety and Hazard-Free Environment Resulting in Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to implement and follow care-planned safety interventions for a resident with significant cognitive and physical impairments. The resident had diagnoses including Alzheimer’s disease, dementia, psychotic disorder with delusions, anxiety, obsessive-compulsive behavior, peripheral vascular disease, convulsions/seizure disorder, and a history of repeated falls. The care plan identified the resident as at risk for falls related to unstable balance, decreased safety awareness, impaired decision-making skills, and lack of coordination, and included interventions such as keeping the bed in the low position with brakes locked and, later, a fall mat to the left side of the bed. A fall risk assessment documented the resident as high risk for falls, and prior falls from bed had resulted in at least one laceration requiring sutures and antibiotic treatment. Despite these known risks and documented interventions, there was no evidence that the care plan was revised to add further bed-related safety interventions after repeated falls from bed. On the night of the fatal incident, the resident, who was dependent on staff for transfers, bed positioning, and turning, was last seen by a CNA around 3:40–3:45 a.m., when incontinence care was provided and the resident was reported to be “alive and fine in bed.” The same CNA later stated that at that time the bed was typically at about “waist high,” rather than in the lowest position. Around 4:50–4:55 a.m., the CNA found the resident lying supine on the floor, partially underneath the bed, with the bed in the lowest position and the corded bed control stretched across the resident’s neck area and pinned under her back near the left shoulder. Witness statements from CNAs and nursing staff, as well as EMS and police narratives, consistently described the resident’s head and torso as being under the bed frame, with visible compression marks on the chest, abdomen, and face consistent with the bed frame and piston, and a chunk of hair lodged in a bolt on the lower bed frame. Staff reported that the bed had to be raised using the remote, which was under the resident, before the resident could be pulled out from under the bed. Investigative interviews and external reports identified additional environmental and supervision-related hazards. A detective observed that a fall alert system was attached to the bed rail but was not plugged in or set up to provide any alert if the resident attempted to get out of bed or fell. The detective also found the call light tucked behind the nightstand, out of the resident’s reach, although it functioned when tested. Multiple staff, including CNAs, nurses, the OT, and the physician, confirmed that the resident could not walk, could not turn herself in bed, was a two-person assist, and was totally dependent on staff for bed position and care. Several staff stated they had never seen a fall mat at the bedside, despite the care plan calling for one, and confirmed that the bed was supposed to be kept in the lowest position due to the resident’s fall risk. The DON and previous administrator acknowledged that the resident was found under the bed with marks consistent with the bed frame and that the bed should have been all the way down to the floor, while also indicating that the incident was considered an accident and that no report had been made to the state survey agency. The surveyors concluded that the facility failed to ensure that care-planned safety interventions (bed in low position, fall mat) were implemented and that the environment (including bed equipment, fall alarm, and call light accessibility) was free of accident hazards, resulting in a serious injury and death for this resident. The facility’s own policy on “Safety and Supervision of Resident” stated that the environment should be made as free from accident hazards as possible and that interventions to reduce accident risks included communicating specific interventions to all relevant staff, providing training, and ensuring interventions are implemented. However, the record showed that after multiple falls, including one with injury, the care plan was not updated with additional bed-related safety measures beyond a single fall mat, and there was no documentation that the existing interventions (bed in low position, brakes locked, fall mat, call light within reach) were consistently implemented. Staff interviews revealed discrepancies about who initiated CPR and who raised the bed, but they consistently indicated that the resident was dependent, that the bed was expected to be in the lowest position, and that the resident’s ability to use the call light or bed remote was limited or absent. External responders (EMS and police) documented that staff did not know how long the resident had been pinned, that the bed’s corded control was found under the resident, and that the fall alert system and call light were not positioned to protect or assist the resident. These combined findings formed the basis for the cited deficiency at F689 for failure to prevent accidents and maintain an environment free of accident hazards.
Failure to Consistently Implement Safety Measures After Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from physical abuse by another resident on two separate occasions. One resident, admitted with chronic kidney disease, essential hypertension, and type 2 diabetes mellitus, had a quarterly MDS BIMS score of 15, indicating intact cognition. Another resident, admitted with aphasia, cognitive communication deficit, chronic kidney disease, and non-Hodgkin lymphoma, had a quarterly MDS BIMS score of 3, indicating severe cognitive impairment. On one date, nursing documentation showed staff were called to the room and observed a CNA removing the cognitively impaired resident from the cognitively intact resident’s room after the latter reported being hit three times on the left arm. A same-day skin assessment documented slight redness above the antecubital area. Following this first incident, the cognitively intact resident’s care plan was revised to include a stop sign on the door as an intervention. Despite this, a second incident occurred when a nurse at the nurse’s station heard yelling in the hall and then observed the cognitively impaired resident exiting the same resident’s room. When questioned, the cognitively intact resident reported that she had asked the other resident to leave and was then hit. The facility’s investigation documented that the residents were separated and that a skin assessment revealed redness to the left upper breast and left index finger knuckle, with no open areas or swelling and the resident denying pain. A later skin assessment the same evening documented no areas of concern. Surveyor observations and interviews showed that the stop sign intervention was not consistently implemented, contributing to the recurrence of resident-to-resident physical contact. An employee warning form documented that a staff member failed to reattach the stop sign across the doorway after returning the resident from an appointment. During surveyor observation, the stop sign was again not in place outside the resident’s room, and no staff were in sight while the resident sat on the side of the bed. The resident reported that the other resident had come into her room on two occasions and struck her and stated that staff did not keep the stop sign up much. An LPN acknowledged that the stop sign was supposed to be in place and admitted forgetting to put it back up after exiting the room. The DON confirmed that physical contact occurred on both dates when the cognitively impaired resident struck the cognitively intact resident, although neither resident sustained injuries.
Failure to Implement Care Plan Intervention for Door Stop Sign
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan intervention for one resident as required by facility policy. The facility’s care plan policy, revised March 2022, states that comprehensive care plans must include measurable objectives and interventions derived from a thorough analysis of information to meet residents’ physical, psychosocial, and functional needs. Resident #15 was admitted with chronic kidney disease, essential hypertension, and type 2 diabetes mellitus, and a quarterly MDS showed the resident was cognitively intact with a BIMS score of 15. The resident’s comprehensive care plan, revised 4/21/2025, included an intervention for a stop sign to be placed on the resident’s door, with staff to assist as needed to keep the stop sign in place. On 4/14/2026 at 8:24 AM, surveyors observed that the stop sign outside Resident #15’s room was not in place, and no staff were in sight of the room while the resident was sitting on the side of the bed. During an interview at 8:25 AM, the resident stated that staff did not keep the stop sign up much anymore. At 8:27 AM, an LPN acknowledged that the stop sign was supposed to be in place and admitted it was their fault, explaining they had forgotten to put the stop sign back up after exiting the resident’s room. At 8:40 AM, the DON, upon interview and medical record review, confirmed that the care plan intervention for the stop sign on the resident’s door had not been followed and stated she expected the stop sign to be in place for this resident.
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