Lauderdale Community Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ripley, Tennessee.
- Location
- 215 Lackey Lane Po Box 186, Ripley, Tennessee 38063
- CMS Provider Number
- 445354
- Inspections on file
- 23
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 43 (1 serious)
Citation history
Health deficiencies cited at Lauderdale Community Living Center during CMS and state inspections, most recent first.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not ensure that a CPR certified staff member was present at all times, as required by policy, with 16 out of 40 days lacking such coverage. This occurred despite a significant number of residents being Full Code and in need of immediate CPR if required. The DON confirmed that continuous CPR certified staff coverage was expected.
The facility did not ensure an RN was on duty for at least 8 consecutive hours daily on multiple occasions, and the DON's nursing license lapsed during the review period. Time sheet reviews and interviews confirmed gaps in RN coverage and a period when the DON did not have an active license, contrary to facility policy and regulatory requirements.
For 31 consecutive days, the facility did not post daily staffing sheets that included the actual hours worked by RNs, LPNs, and CNAs. Observations and interviews confirmed that the required information was missing from the posted sheets, and the DON acknowledged the omission.
The facility did not provide adequate dietary staff with the required competencies after the Dietary Manager was terminated, resulting in unsanitary kitchen conditions and insufficient food supplies, including the lack of a 3-day emergency food supply. The RD confirmed not knowing how to fulfill key job duties, and observations revealed multiple sanitation issues in the kitchen and storage areas.
The facility did not serve meals as listed on the posted menus for three consecutive days, instead making multiple substitutions due to lack of inventory. The RD confirmed that the posted menus should be followed to meet residents' nutritional needs, but necessary food items were unavailable, resulting in changes to main dishes, sides, and desserts for all residents receiving meals.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The QAPI Committee did not identify or address ongoing issues with supervision, infection control, and staff competency. Meeting minutes were incomplete, and there was no evidence of infection control review. An LPN used a blood glucose meter on a resident, cleaned it improperly, and then prepared to use it on another resident without proper disinfection. There was no documentation of staff education on proper cleaning protocols, and supervisory audits were inconsistent or undocumented.
A resident with severe cognitive impairment and multiple medical conditions did not receive required care plan interventions for hydration and nutrition. Staff failed to ensure water was within reach, did not provide scheduled snacks, and did not offer necessary assistance during meals, as confirmed by observations and staff interviews.
A resident with severe cognitive impairment, as indicated by a low BIMS score and multiple diagnoses including dementia, was not provided with a care plan conference that included their family representative. Despite facility policy requiring family involvement for such residents, only the resident was invited to care plan meetings, and the family representative was not contacted or included.
The facility did not ensure that a resident received proper care for existing pressure ulcers and failed to implement adequate preventive measures to stop new ulcers from developing.
Nursing staff left an open and unattended razor on a bedside table next to a resident who was dependent on staff for personal hygiene and had a history of using objects to scratch their skin. Facility policy required immediate disposal of sharps, but this was not followed, as confirmed by both an LPN and the DON.
The facility did not ensure adequate nursing staff or maintain a licensed nurse in charge on each shift, as required by policy. On multiple days, staffing records showed insufficient RN and LPN coverage, with PPD nursing hours below expectations and no 24-hour nursing presence, as confirmed by the DON. The facility also received a low staffing rating and could not provide all requested timesheet documentation.
Staff failed to secure and properly store medications and biologicals, including leaving refrigerated medications at incorrect temperatures, not maintaining complete temperature logs, and leaving medication rooms and carts unlocked and unattended. These actions resulted in medications being accessible and potentially compromised.
Staff responsible for caring for residents with severe cognitive impairment did not receive required behavioral health or dementia care training. Multiple staff members, including CNAs and a housekeeper, confirmed they had not received formal training, and the facility's training system lacked dementia care modules. This deficiency was identified through medical record review and staff interviews involving residents with dementia and related diagnoses.
A resident with severe cognitive impairment and a history of wandering exited the facility through a malfunctioning, unsecured door without staff awareness. The door alarm did not sound, and the resident was later found outside with head injuries after traveling down an embankment. Staff were unaware of the elopement until notified by police, and subsequent inspection revealed multiple security and maintenance failures with exit doors and alarms.
The facility failed to securely store medications, with instances of medications left unattended in residents' rooms and an unlocked medication cart. Residents self-administered medications without proper authorization, and opened, undated, and expired medications were found in the storage room. Staff confirmed these actions were against policy.
The facility failed to maintain sanitary conditions in food preparation and serving areas, with issues such as a brown dried liquid on the oven door, carbon buildup on frying pans, and a rusted mesh skimmer. Wet nesting of steam table pans and a shiny film on the convection oven were also observed. The DM confirmed these issues, acknowledging the need for cleaning and replacement. The facility's cleaning policy was not followed, affecting meal service for 34 residents.
Two nurses failed to follow infection control practices during medication administration for two residents. An LPN did not perform hand hygiene before donning gloves, and an RN failed to clean a stethoscope after use, despite facility policies requiring these actions. The DON confirmed the necessity of these practices.
A facility failed to accurately assess a resident with wandering behavior, resulting in a deficiency. Despite the care plan identifying the resident as an elopement risk and wanderer, the quarterly MDS assessments did not reflect this behavior. Observations confirmed the resident's wandering, and interviews with the DON and MDS Coordinator acknowledged the oversight.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Ensure 24/7 Presence of CPR Certified Staff
Penalty
Summary
The facility failed to ensure that a staff member certified in Cardiopulmonary Resuscitation (CPR) was present in the facility at all times, as required by facility policy and necessary for the care of residents. Review of employee timesheets over multiple date ranges revealed that for 16 out of 40 days reviewed, there was not a CPR certified staff member working in the facility for the full 24-hour period. The facility census was 35 at the time of survey entrance, and a review of the Resident Status List showed that 30 out of 52 residents were listed as Full Code, indicating they would require CPR in the event of cardiac or respiratory arrest. During an interview, the Director of Nursing (DON) confirmed that a CPR certified staff member should be present at all times.
Failure to Maintain RN Coverage and Active DON License
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, for 15 out of 54 days reviewed. This was identified through a review of facility policy, employee time sheets, and interviews. The facility's staffing policy requires sufficient numbers of staff with the necessary skills and competency to provide care and services for all residents. However, time sheet reviews revealed multiple dates where no RN was present for the required 8-hour period, and the facility was unable to provide additional documentation for those dates when requested. During interviews, the DON acknowledged that there should be an RN on duty daily and confirmed that her own time was sometimes manually entered when she covered RN shifts, but also noted she was off during one of the weeks in question. Additionally, the facility failed to ensure that the Director of Nursing (DON) maintained a current and active nursing license during the review period. A check of the State of Tennessee Department of Health Division of Health Licensure website showed the DON's license had lapsed, and the DON confirmed in an interview that her license had expired and was later renewed. These findings indicate lapses in both staffing and licensure compliance as required by facility policy and state regulations.
Failure to Post Actual Hours Worked on Daily Staffing Sheets
Penalty
Summary
The facility failed to post daily staffing sheets that included the actual number of hours worked by Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNA) for a period of 31 consecutive days. Review of the posted daily staffing sheets from 7/12/2025 to 8/11/2025 showed that the required information was missing. Multiple observations in the facility's front entrance lobby on different dates confirmed that the posted sheets did not include the actual hours worked by each discipline. During an interview, the Director of Nursing (DON) acknowledged that the posted daily staffing sheets should have included this information, but the deficiency persisted throughout the observed period.
Insufficient Dietary Staffing and Poor Kitchen Sanitation
Penalty
Summary
The facility failed to provide sufficient staff with the necessary competencies and skill sets to carry out the functions of the food and nutrition services after the Dietary Manager was terminated. Policy review indicated that support services staff, including dietary, are required to ensure resident needs are met. Observations over several days revealed the kitchen lacked standard cleaning schedules, with evidence of poor sanitation such as dried substances and loose particles on food containers, unclean stainless steel tables and storage racks, and a powdery substance on the floor and boxes in the dry storage area. The ice machine was also found with dried spills and white streaks both inside and outside. Interviews confirmed that the Dietary Department was operating without a Dietary Manager, and the Registered Dietitian (RD) admitted to not knowing how to perform the necessary job functions, including ordering adequate food supplies. The RD also confirmed the absence of a required 3-day emergency food supply, stating that the previous Dietary Manager would deplete this supply to compensate for insufficient regular food orders. The Administrator verified that the Dietary Manager had been let go due to lack of competencies and skill sets necessary for the role.
Failure to Serve Meals According to Posted Menus
Penalty
Summary
The facility failed to serve food items as listed on the posted menus for three consecutive days during the recertification survey. Review of the menus and direct observation revealed that the meals served did not match the planned menus for each day. On multiple occasions, substitutions were made due to the lack of necessary food items in inventory, as confirmed by the Registered Dietitian. For example, instead of serving beef ravioli, pork riblet, and cornmeal crusted chicken as planned, the facility served meat loaf, roast pork, and pulled pork, among other substitutions. Additionally, side dishes and desserts were also changed from what was originally posted. The Registered Dietitian confirmed that the posted menu should be followed to meet the nutritional needs of the residents, and acknowledged that the changes were made because the required food items were not available. The census at the time was 35, with all residents receiving meals that did not align with the posted menus. There is no mention of specific residents' medical histories or conditions in the report.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
QAPI Committee Failed to Address Infection Control and Supervision Deficiencies
Penalty
Summary
The QAPI Committee failed to identify and address ongoing quality deficiencies, including inadequate supervision, ineffective infection control practices, and lack of staff competency in resident care. Meeting minutes from April, May, and June 2025 showed blank or incomplete documentation, with no evidence of infection control review or nursing department oversight. The committee did not perform root cause analysis, develop corrective plans, or ensure implementation of systems to maintain acceptable standards. There was also a lack of clinical guidance and oversight for resident care policies and procedures. During direct observation, an LPN used a multi-use blood glucose meter on one resident, cleaned it with a hand sanitizing wipe not recommended by the manufacturer, and then prepared to use it on another resident without proper disinfection. The facility could not provide documentation of staff education on blood glucose monitoring or cleaning protocols prior to the incident. Interviews with the DON and Administrator confirmed inconsistent or undocumented supervision and audits, and the Medical Director had not participated in a QAPI meeting to discuss the Immediate Jeopardy event.
Failure to Implement Hydration and Nutrition Care Plan Interventions
Penalty
Summary
The facility failed to implement care plan interventions for a resident with significant medical needs, including Alzheimer's Disease, dysphagia, diabetes, abnormal weight loss, and congestive heart failure. The resident was assessed as having severe cognitive impairment and required total assistance with eating. The care plan specified that the resident should have access to cool, fresh water at the bedside and receive snacks at 10:00 AM and 2:00 PM due to ongoing weight loss. Observations revealed that the water pitcher was repeatedly placed out of the resident's reach, and staff did not ensure the resident had access to water as required by the care plan. Additionally, staff did not provide the necessary assistance during meals, as a CNA set up the meal tray and encouraged the resident to eat but did not remain to provide further help or encouragement. The resident was also observed attempting to eat breakfast without staff present to assist, despite needing total assistance. Interviews with staff confirmed that the resident had not received the scheduled snacks and that the care plan interventions were not being followed as required.
Failure to Involve Family Representative in Care Planning for Cognitively Impaired Resident
Penalty
Summary
The facility failed to conduct a care plan conference with the family representative for one resident who was severely cognitively impaired. According to facility policy, residents and their family members are to be encouraged to participate in the development of the comprehensive assessment and care plan, and representatives are to be invited to care planning conferences. Medical record review showed that the resident was admitted with diagnoses including dementia, diabetes, hypertension, and COPD, and had a Brief Interview for Mental Status (BIMS) score of 4 or 5, indicating severe cognitive impairment. Despite this, the resident's family representative reported never being invited to a care plan meeting. Interviews with facility staff revealed that the Social Service Director considered the resident to be his own responsible party and stated that only the resident was invited to care plan meetings. However, the Director of Nursing confirmed that with a BIMS score of 5, the resident should not be considered their own responsible party and that the family should have been invited to participate in care planning. This failure to involve the family representative in the care planning process for a resident with severe cognitive impairment was identified through policy review, medical record review, and staff and family interviews.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents either did not receive necessary interventions for existing pressure ulcers or were not provided with adequate preventive care to avoid the formation of new pressure ulcers.
Unattended Razor Left at Bedside
Penalty
Summary
Nursing staff failed to provide an environment free from accident hazards by leaving an open and unattended razor on a bedside table next to a resident's bed. Facility policy requires that contaminated sharps be discarded immediately into designated containers, but this protocol was not followed. The open razor was observed during a room check, and both an LPN and the Director of Nursing confirmed that razors should not be left open and unattended. The resident involved had a history of cerebral infarction, PTSD, anxiety, diabetes, depression, and seizures, and was assessed as cognitively intact but dependent on staff for personal hygiene, including shaving. The resident's care plan noted a risk for behaviors related to using objects to scratch the skin, which had previously led to skin compromise. Despite these risks, the razor was left accessible at the bedside, contrary to facility policy and the resident's care needs.
Failure to Provide Sufficient Nursing Staff and 24-Hour Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents and to ensure a licensed nurse was in charge on each shift, as required by facility policy and federal regulations. Review of the facility's staffing policy indicated that licensed nurses and certified nursing assistants (CNAs) should be available 24 hours a day, with staffing levels determined by resident care needs. However, analysis of the CMS Payroll-Based Journal (PBJ) Staffing Data Report and employee timesheets for the second quarter of 2025 revealed that on eight separate days, the facility did not meet these requirements. Specifically, there were days when no Registered Nurse (RN) or Licensed Practical Nurse (LPN) was present for a full 24-hour period, and the per patient day (PPD) staffing hours were below expected levels. The facility also received a 1-star staffing rating and was unable to provide additional requested timesheet documentation for the identified dates. Interviews confirmed the deficiency, with the Director of Nursing (DON) acknowledging that a nurse should always be present in the facility. The census during the period in question ranged from 32 to 39 residents, and on the identified dates, the facility failed to provide the required 24 hours of nursing coverage. This lack of adequate staffing was directly observed through the review of timesheets and staffing data, and no additional information about specific residents' medical histories or conditions was provided in the report.
Failure to Secure and Properly Store Medications and Biologicals
Penalty
Summary
Facility staff failed to ensure proper storage and security of medications and biologicals as required by policy and professional standards. Refrigerated medications were found stored outside the recommended temperature range, with the medication refrigerator observed at 65°F due to an ajar door caused by ice buildup, and water was present on the refrigerator floor and on medications. The refrigerator contained various insulin products, Tuberculin Serum, and an emergency supply box with additional medications. Temperature logs for the medication refrigerator were incomplete and inconsistent for several months, with multiple days missing entries. The Director of Nursing confirmed that medications stored outside the recommended temperature range could be rendered ineffective and that temperature logs should be maintained daily. Additionally, two LPNs were observed leaving the medication room unlocked and unattended, with medications accessible and out of staff sight for several minutes on separate occasions. The medication cart in the B Hall was also found unlocked and unattended beside the nurses' station. Staff interviews confirmed that these actions were contrary to facility policy, which requires all medication storage areas to be locked and attended by authorized personnel at all times.
Failure to Provide Behavioral Health and Dementia Training to Staff
Penalty
Summary
The facility failed to provide required behavioral health training, specifically dementia care training, to staff responsible for residents with severe cognitive impairment. Medical record reviews showed that three residents with diagnoses including dementia, Alzheimer's disease, and other significant comorbidities were under the care of staff who had not received formal training in dementia management. The Minimum Data Set (MDS) assessments for these residents indicated severe cognitive impairment, with BIMS scores ranging from 3 to 6. Despite these residents' needs, the facility was unable to provide documentation of any behavioral health or dementia-specific training for its staff. Interviews with staff members, including CNAs and a housekeeper, confirmed the lack of formal dementia care training. One CNA reported receiving only informal guidance from another aide during orientation, while others stated they had not received any dementia training at all. The Regional Nurse acknowledged that the facility's computerized training system did not include dementia care modules, and confirmed the absence of such training for staff. This lack of training was consistent across both new and long-term employees, as evidenced by their statements during interviews.
Failure to Prevent Elopement Due to Malfunctioning Exit Door and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, hallucinations, and a history of exit-seeking and wandering behaviors eloped from the facility without staff knowledge. The resident was able to exit through an unlocked and unsecured door on C Hall that malfunctioned and did not trigger an alarm. The resident left his wheelchair at the door, traveled down a steep embankment, and was found on the ground near a two-way street by a passerby, having sustained head injuries that required hospital evaluation. At the time of the incident, the temperature outside was 37 degrees Fahrenheit, and facility staff were unaware that the resident had left the building until notified by local law enforcement. Review of facility policies indicated that residents at risk for wandering or elopement were to be monitored and necessary precautions taken to ensure their safety. However, documentation and staff statements revealed that the exit door alarm did not function properly, and the door had a history of malfunctioning for close to a year. Additionally, window alarms in a resident room near the exit were found to be nonfunctional during a subsequent facility tour, and other doors and hardware were observed to be in disrepair or not properly secured. Staff interviews confirmed that no alarm sounded when the resident exited, and the maintenance director acknowledged longstanding issues with the door's closure mechanism. The facility's failure to provide adequate supervision and maintain a secure environment resulted in the resident's unsupervised exit and subsequent injury. The incident was not immediately detected by staff, and the resident was only discovered after being found by a member of the public and reported to the police. The facility's lack of effective monitoring and failure to address known safety hazards with exit doors and alarms directly contributed to the resident's elopement and injury.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper and secure storage of medications, as evidenced by several observations and interviews. Medications were left unattended in residents' rooms, including a medication cup with 13 medications and 2 eye drops left on a resident's over-the-bed table by an LPN. Another resident was observed self-administering approximately 15 pills without proper authorization or assessment. Additionally, medications were left at the bedside of other residents, including a cream and wound cleanser, which were confirmed by staff to be against policy. Furthermore, a medication cart was left unlocked and unattended during administration, and the medication storage room contained opened, undated, and expired medications. A vial of Tuberculin was found opened and undated, and Osmolite nutritional supplements were opened and not discarded within the required timeframe. These findings indicate a failure to adhere to the facility's policies on medication storage and administration, as confirmed by interviews with the Director of Nursing and other staff members.
Sanitation Deficiencies in Food Preparation and Serving Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the food preparation and serving areas, as evidenced by several observations and interviews. The oven door was found to have a brown dried liquid on the glass and top, and there was a significant carbon buildup on three frying pans. Additionally, a rusted mesh skimmer was observed hanging with the frying pans. The Director of Food and Nutrition Services (DM) confirmed these issues during interviews, acknowledging the need for cleaning and replacement of the affected items. Further observations revealed that steam table pans were wet nesting on top of each other, which was confirmed by the DM as inappropriate. The top of the convection oven and its doors were also noted to have a shiny film, indicating a lack of cleanliness. The facility's policy on cleaning schedules, dated 8/31/2018, mandates that the Food and Nutrition Services staff maintain sanitation through compliance with comprehensive cleaning schedules, which was not adhered to in this instance. The facility had a census of 34 residents, all of whom received meal trays from the kitchen, potentially impacting their meal service.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to adhere to infection control practices during medication administration for two residents. Specifically, two nurses, an LPN and an RN, did not perform hand hygiene as required by the facility's policies. The LPN did not wash hands before donning gloves while administering medication to a resident with chronic kidney disease, polyneuropathy, anxiety, and depression. This oversight occurred despite the facility's policy mandating hand hygiene before and after direct contact with residents and before handling medications. Additionally, the RN failed to sanitize reusable equipment after exiting a resident's room with enhanced barrier precautions. The RN did not clean the stethoscope after checking the placement of a PEG tube for a resident with multiple diagnoses, including stroke, anemia, coronary artery disease, heart failure, hypertension, diabetes, hemiplegia, and seizure. The RN placed the stethoscope around her neck without cleaning it, only doing so after being prompted. The Director of Nursing confirmed that proper hand hygiene and cleaning of reusable equipment with a bleach wipe are required practices.
Failure to Accurately Assess Wandering Behavior
Penalty
Summary
The facility failed to accurately assess a resident with wandering behavior, leading to a deficiency in the accuracy of assessments. The facility's policy on Elopement/Unsafe Wandering Plan requires residents to be evaluated for unsafe wandering or elopement potential during each care planning review. Resident #32, who was admitted with diagnoses including cognitive deficits, vascular dementia, and Alzheimer's disease, was identified as an elopement risk and wanderer in the care plan. However, the quarterly Minimum Data Set (MDS) assessments did not reflect this behavior, as they indicated that wandering behavior was not exhibited. Observations over several days confirmed that Resident #32 was wandering aimlessly within the facility. Interviews with the Director of Nursing and the MDS Coordinator confirmed that Resident #32 was indeed a wanderer and should have been coded as such on the MDS.
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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