Maplewood Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, Tennessee.
- Location
- 100 Cherrywood Place, Jackson, Tennessee 38305
- CMS Provider Number
- 445412
- Inspections on file
- 26
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Maplewood Health Care Center during CMS and state inspections, most recent first.
Failure to Use PPE During Isolation Care and Medication Administration: Staff did not use required PPE during resident care and medication-related tasks. A CNA entered a resident’s room on droplet/contact precautions and handled a meal tray without PPE, an LPN performed PICC-related care and repositioning in the same room without appropriate PPE, an LPN administered G-tube medications in an EBP room without a gown, and another LPN gave a subcutaneous injection without gloves. The residents involved had diagnoses including ESBL UTI, influenza, chronic kidney disease, diabetes, dysphagia, and other chronic conditions.
A staffing deficiency in an LTC facility led to Immediate Jeopardy when a resident experienced a change in condition without a nurse available for assessment, resulting in a 911 call and hospital admission. Another resident missed a morning blood glucose check and medications, leading to a dangerously high blood glucose level. The deficiency was due to a nurse not reporting to work, leaving one LPN to cover two halls, and a delay in contacting the on-call nurse.
The facility failed to prevent and adequately treat pressure ulcers for two residents. One resident developed a preventable pressure ulcer on her hand due to long fingernails, while another resident with a Stage 4 sacral ulcer missed multiple treatments. The facility's records showed inconsistencies in documenting skin assessments and treatments, and the Interim DON confirmed that treatments should not be missed.
A resident with multiple diagnoses and high fall risk fell twice due to the facility's failure to implement required two-person assistance for bed mobility. The CNA involved was unaware of the care plan, leading to the resident sustaining a fractured hip. The facility's oversight resulted in actual harm to the resident.
The facility failed to maintain sanitary conditions in its kitchen, with observations of dirty floors, equipment, and carts. Additionally, the facility did not adhere to its policies for monitoring and documenting food and equipment temperatures, with numerous missing logs. Staff interviews confirmed these deficiencies, acknowledging the unclean state and lack of documentation.
The facility did not provide a private space for a Resident Council meeting, as required by policy. During the meeting, the Maintenance Director and Assistant entered the room, disrupting the residents. Interviews with the Activity Director and DON confirmed the need for privacy, highlighting a failure to adhere to policy and residents' rights.
The facility did not provide a private space for a Resident Council meeting, as required by policy. During the meeting, the Maintenance Director and Assistant entered the room, disrupting the session. Interviews with the Activity Director and DON confirmed the need for privacy during such meetings.
A resident with severe cognitive impairment was transferred to a hospital without the facility notifying the resident's legal representative, as required by policy. The facility's progress note inaccurately stated that the responsible party was aware, but the notification only occurred after the hospital informed the resident's daughter, who then contacted the facility. The Interim DON acknowledged that notification should occur within an hour of transfer.
The facility failed to maintain a sanitary environment in several resident rooms, with observations of unclean conditions such as dirty baseboards, splatter marks on blinds, and sticky floors with odors. Interviews confirmed that the facility's cleaning standards were not met, as rooms and bathrooms should be clean and odor-free.
The facility failed to report allegations of abuse and an injury of unknown origin involving three residents. A resident reported verbal abuse by a staff member, which was not reported to the state agency for nine days. Another resident, who was severely cognitively impaired, had a bruise on her forehead that was not documented or investigated. A third resident reported a physical altercation with a nurse, which was initially treated as a complaint rather than abuse. The facility acknowledged the need for documentation and investigation in these cases.
The facility failed to investigate alleged abuse incidents involving two residents. One resident, who was severely cognitively impaired, had a bruise on the forehead that was not documented or investigated. Another resident, who was cognitively intact, reported an incident involving a nurse that was not classified as abuse by the facility. The lack of thorough investigation and documentation indicates a deficiency in handling abuse allegations.
A facility failed to develop a comprehensive care plan for a resident at risk for pressure injuries. Despite the facility's policy requiring documentation and communication of interventions, the care plan lacked necessary interventions for wound care to the resident's hand. The MDS Coordinator confirmed the absence of required interventions, highlighting a failure to adhere to policy and address the resident's care needs.
The facility did not conduct a quarterly care plan conference with a resident or their family representative, as required by policy. The resident, who has multiple health issues and is dependent on staff, did not have a documented care plan meeting following their quarterly MDS assessment. Interviews confirmed the omission of the family representative in the care planning process.
A facility failed to maintain accurate records and reconcile controlled medications for a nurse observed during medication administration. Discrepancies were found in the narcotic reconciliation records for three residents, with differences between the controlled drug records and the actual counts of medications like Gabapentin, Alprazolam, and Hydrocodone/Acetaminophen. The LPN admitted to administering doses without updating the narcotic book, and the Interim DON confirmed that narcotics should be signed out immediately after administration.
The facility failed to properly store and label medications, as expired Humalog pens were found in the medication room, and an over-the-counter medication was improperly stored in a shared bathroom. The Assistant Director of Nursing and Interim DON confirmed these storage practices were incorrect.
An LPN failed to follow proper infection control procedures during ostomy care for a resident with multiple diagnoses, including Dementia and Quadriplegia. The LPN did not change gloves or wash hands after cleaning the stoma and before applying a new ostomy bag, contrary to the facility's hand hygiene policy. This was confirmed by the LPN and nursing leadership.
Failure to Use PPE During Isolation Care and Medication Administration
Penalty
Summary
The facility failed to maintain and ensure the prevention and spread of infection when staff did not use PPE during care and medication-related activities for residents on Transmission-Based Precautions and Enhanced Barrier Precautions. The facility policies reviewed stated that staff should don appropriate PPE before or upon entry into a resident’s environment on transmission-based precautions, and that gowns and gloves are required for contact precautions and targeted high-contact care activities under enhanced barrier precautions. Resident #7 was admitted with diagnoses including UTI with ESBL resistance and influenza, and had physician orders for Contact Isolation related to ESBL in urine and Droplet Precautions related to flu. During observation, a CNA entered the resident’s room carrying a dining tray, placed the tray on the over-bed table, and assisted with the meal without donning PPE. Later, an LPN entered the same room, removed tubing from the resident’s PICC line, and turned and repositioned the resident without wearing the appropriate PPE. The ICP stated staff should dress out with all PPE, including gown, gloves, and mask, and should do so when delivering trays or having close contact with a resident in isolation. Resident #47 had diagnoses including chronic kidney disease, dysphagia, diabetes, and a gastrostomy tube, and was severely cognitively impaired. During medication administration through the G-tube, an LPN prepared crushed medications and liquids, entered the resident’s room without donning PPE, performed hand hygiene, donned gloves, checked tube placement and residual, and administered the medications through the G-tube. The LPN did not wear a gown in the EBP room. Resident #114 had diagnoses including diabetes, atrial fibrillation, anemia, and kidney disease, and was moderately cognitively impaired. During medication administration, an LPN entered the resident’s room and gave a subcutaneous Repatha injection without donning gloves. The DON stated gloves should be worn when administering an injection.
Staffing Deficiency Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to provide sufficient licensed nursing staff to perform necessary assessments and administer morning medications as ordered for six residents. This deficiency resulted in Immediate Jeopardy when a resident experienced a change in condition, and no nurse was available to assess the resident. The resident's spouse had to call 911, leading to the resident being evaluated in the Emergency Department and admitted to the hospital. Another resident did not receive a morning blood glucose check, scheduled insulin, or Metformin, resulting in a dangerously high blood glucose level later in the day. The facility's staffing issues were evident on a specific day when a scheduled nurse did not report to work, leaving one LPN to cover two halls with a total of 49 residents. This LPN was unable to provide care for the residents on one hall due to the workload on the other hall, which included a hospice resident requiring significant attention. The on-call nurse was not contacted until several hours into the shift, and by the time they arrived, the residents had already missed their scheduled medications and assessments. Interviews with staff and documentation reviews revealed a breakdown in communication and staffing procedures. The DON was informed early in the shift about the absence of the scheduled nurse but did not ensure that the on-call nurse was contacted promptly. The staffing coordinator was not notified until midday, and the on-call nurse did not arrive until nearly seven hours after the shift began. This delay in staffing coverage led to significant lapses in resident care, including missed medication administrations and assessments.
Removal Plan
- Education was provided to the RDCS, Administrator, and Director of Nursing by the VP of Clinical Services and the Chief Operating Officer regarding On-Call Procedures.
- The off going nurse will remain at the facility to complete medication administration and to ensure resident care is continued until the Nurse Manager on call or oncoming nurse has arrived to relieve the off going charge nurse.
- Procedure of notifying the physician following assessing all potentially affected residents for further direction of action related to delayed or missed medication administration.
- Ongoing monitoring plan to prevent recurrence.
- All hall residents were evaluated for delayed medications by the Director of Nursing and Licensed Practical Nurse.
- All applicable Residents' blood glucose levels were assessed per accucheck with physician notification completed.
- The Medical Director was notified by the DON for notification of all delayed medications and missed accuchecks and insulin administration with current blood glucose levels obtained.
- The Medical Director was included in adhoc Quality Assurance and Performance Improvement (QAPI) meeting.
- All on duty Licensed Nurses were educated by the Director of Nursing and Regional Director of Clinical Services regarding On-call procedures, communication, timely medication administration, reinstructed regarding abuse prohibition and neglect, and staffing procedures.
- The Director of Nursing and Regional Director of Clinical Services completed a Medication Administration audit for all residents.
- A Governing Body meeting was held with the Administrator, Director of Nursing, Regional Director of Clinical Services, and VP of Clinical Services to discuss the notification of immediate jeopardy.
- Adhoc QAPI meeting held with the Medical Director to share Removal and in agreement with Plan of Correction and Monitoring in place.
- The Director of Nursing and/or Assistant Director of Nursing will audit medication administration competition.
- Monitoring will occur twice daily, then twice daily during business days, then weekly thereafter during morning clinical meeting.
- The Director of Nursing will report the findings to the monthly QAPI Committee meeting.
- Removal plan was discussed and approved by Medical Director.
- The Administrator will ensure the removal plan is completed.
Failure in Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development of pressure ulcers and to treat existing ones for two residents. One resident, who was at risk due to contractures and required assistance with activities of daily living, developed a pressure ulcer on the palm of her left hand due to long fingernails digging into the skin. Despite being cognitively intact, the resident was dependent on staff for personal care, including nail trimming, which was not adequately performed. The facility's records showed inconsistencies in documenting skin assessments and treatments, and the wound was not identified in a timely manner. Another resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, had a Stage 4 pressure ulcer on the sacral area. The facility's treatment administration records revealed multiple instances where prescribed treatments for the pressure ulcer were missed. The Interim Director of Nursing confirmed that treatments should not be missed and that any missed treatments should be documented with a reason. Interviews with the treatment nurse and the Director of Nursing confirmed that the pressure ulcer on the first resident's hand was preventable and should have been identified during routine skin assessments. The facility's failure to adhere to its policies on pressure injury prevention and management, as well as the lack of documentation and follow-through on prescribed treatments, contributed to the deficiencies identified in the care of these residents.
Failure to Implement Fall Interventions Results in Resident Injury
Penalty
Summary
The facility failed to implement fall interventions for a resident, resulting in actual harm. The resident, who was admitted with multiple diagnoses including left hemiplegia, Parkinson's, and dementia, was assessed as high risk for falls. Despite this, the facility did not adhere to the care plan that required two-person assistance for bed mobility. On two separate occasions, the resident fell from the bed, sustaining injuries including a fractured hip. On the first incident, the resident was found on the floor with multiple injuries, and it was noted that two staff members were required for assistance. However, during the second incident, a CNA was providing care alone when the resident fell again, leading to a hip fracture. The CNA involved was unaware of the two-person assistance requirement, as they had just started working on that side of the facility. Interviews with staff revealed that the CNA was not informed of the resident's care plan requirements, and the RN on duty was not present during the fall. The resident, who was cognitively intact, expressed pain and was eventually transferred to the hospital for evaluation and treatment. The facility's failure to follow the established care plan and ensure adequate supervision directly contributed to the resident's injury.
Sanitation and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as evidenced by multiple observations of unclean equipment and surfaces. The kitchen floor was consistently found to be dirty with dried food crumbs and debris, and the convection oven had a significant buildup of dried food particles and a thick black sticky substance. Additionally, various carts used for meal service and storage were observed to be dirty and contained food particles. The facility also failed to adhere to its own policies regarding the monitoring and documentation of food and equipment temperatures. Logs for food temperatures, freezer temperatures, cooler temperatures, and dish machine sanitation were incomplete or missing for numerous days across several months. This lack of documentation indicates a failure to ensure that food was stored, prepared, and served at safe temperatures, and that dishwashing equipment was operating under sanitary conditions. Interviews with facility staff, including the Registered Dietician and Certified Dietary Manager, confirmed these deficiencies. The staff acknowledged the unclean state of the kitchen and the failure to document required temperature checks. The Certified Dietary Manager admitted to not enforcing the necessary standards and expressed awareness of the facility's shortcomings in maintaining compliance with state regulations.
Failure to Provide Privacy for Resident Council Meeting
Penalty
Summary
The facility failed to provide a private space for the Resident Council meeting, as required by their policy titled 'Resident Council Procedural Guide' dated 11/28/2017. During the meeting held in the Dining Room, the Maintenance Director and Maintenance Assistant entered the room and walked in front of the residents, disrupting the meeting. Interviews with the Activity Director and the Director of Nursing confirmed that a private place should be provided for uninterrupted resident council meetings, indicating a failure to adhere to the facility's policy and the residents' rights to privacy during their meetings.
Failure to Provide Private Space for Resident Council Meeting
Penalty
Summary
The facility failed to provide a private space for the Resident Council meeting, as required by their policy. The policy, dated 11/28/2017, states that residents have the right to organize and participate in resident groups and must be provided with privacy for meetings. During a Resident Council meeting in the Dining Room, the Maintenance Director and Maintenance Assistant entered the room and walked in front of the residents, disrupting the meeting. Interviews with the Activity Director and the Director of Nursing confirmed that a private place should be provided for uninterrupted resident council meetings.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify the legal representative of a resident about the resident's transfer to a hospital, which is a requirement according to the facility's policy. The policy mandates that the resident's family member or legal representative must be informed of any significant changes, including transfers or discharges. In this case, the resident, who had severe cognitive impairment due to conditions such as Dysphagia, Dementia, Alzheimer's Disease, and Gastro-Esophageal Reflux, was transferred to a hospital following episodes of vomiting. The facility's progress note indicated that the responsible party was aware of the transfer, but this notification occurred only after the hospital had already informed the resident's daughter, who then contacted the facility for confirmation. Interviews conducted during the investigation revealed that the resident's responsible party was not notified by the facility at the time of the transfer. The Interim Director of Nursing stated that the responsible party should be notified within an hour of the transfer, acknowledging that immediate notification might not occur in emergencies but should happen as soon as the resident is out of the building. This failure to promptly notify the responsible party of the resident's transfer constitutes a deficiency in the facility's adherence to its notification policy.
Facility Fails to Maintain Sanitary Environment in Resident Rooms
Penalty
Summary
The facility failed to maintain a sanitary environment in several resident rooms, as evidenced by multiple observations of unclean conditions. In Resident #3's room, dirty baseboards and window blinds with yellowish-brown splatter marks were noted. The commode had a grayish-black ring and a dark brown smear above the water line. In the shared bathroom of Residents #82 and #94, a strong odor of urine was present, and the floor was sticky with visible footprints and wheelchair marks. Dirt, crumbs, and dark streaks were observed on the floor and walls. In the room shared by Residents #34 and #61, the window valance had a thick gray dusty buildup. In the room of Residents #28 and #84, the base of the enteral feeding tube pole had a yellowish tan hardened substance, and crumbs and dirt were present on the floor. Interviews with the Administrator and the Head of Housekeeping confirmed that the facility's cleaning standards were not met, as resident rooms and bathrooms should be clean, odor-free, and without visible dust or dirt.
Failure to Report Allegations of Abuse and Injury
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving Resident #76, who was cognitively intact with a BIMS score of 15. The resident reported to a surveyor that a staff member called him a derogatory name. Although the surveyor informed the Administrator of the allegation, it was not reported to the state agency until nine days later. The Administrator acknowledged the failure to report the incident promptly. Resident #81, who was severely cognitively impaired with a BIMS score of 00, was found with a bruise on her forehead, which was not documented or investigated by the facility staff. The bruise was first noted in a progress note, but subsequent skin checks did not report it. The resident's daughter discovered the bruise when the resident was hospitalized, and the facility later acknowledged the need for documentation and investigation of the injury. Resident #307, who was cognitively intact, reported an incident where a nurse allegedly tried to take his phone, leading to a physical altercation. The resident claimed the nurse put a towel over his face, which he perceived as smothering. The incident was initially reported as a complaint rather than abuse, and the Administrator did not report it to the state agency until later. The Administrator and Social Service Director did not perceive the incident as abuse, despite the resident's account.
Failure to Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to thoroughly investigate alleged abuse incidents involving two residents. For Resident #81, who was severely cognitively impaired, a bruise was noted on the forehead, but no incident report or investigation was conducted. The bruise was first observed on 12/25/2024, but it was not documented or reported as required by the facility's policy. The resident's daughter was not informed of the incident by the facility, and the bruise was only noted when the resident was hospitalized. Interviews with staff revealed a lack of clarity on the origin of the bruise, and the Interim DON confirmed that the incident should have been documented and investigated immediately. For Resident #307, who was cognitively intact, an incident occurred where the resident called 911, alleging that a nurse attempted to take his phone and subsequently restrained him with a towel over his face. The resident reported feeling unsafe and wanted to press charges. However, the facility's administration did not classify the incident as abuse, instead treating it as a complaint. The Administrator and Social Service Director did not perceive the incident as abuse, and the facility did not conduct a thorough investigation or report it as required. The facility's failure to investigate these incidents thoroughly and document them as per policy indicates a deficiency in handling allegations of abuse. The lack of immediate and appropriate response to these incidents, including failure to notify family members and conduct proper investigations, highlights a significant oversight in the facility's adherence to its policies on abuse, neglect, and incident reporting.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident identified as being at risk for pressure injuries. The facility's policy on Pressure Ulcer Prevention and Management mandates that nursing assistants inspect the skin during baths and report any concerns to the resident's nurse in a timely manner, with interventions documented in the care plan and communicated to all relevant staff. However, the care plan for the resident, who was admitted with diagnoses including Hemiplegia, Epilepsy, and knee contractures, lacked necessary interventions for wound care to the palm of the left hand, despite the resident being cognitively intact and requiring substantial assistance with activities of daily living (ADLs). The deficiency was confirmed during an interview with the Minimum Data Set (MDS) Coordinator, who acknowledged that there should have been an intervention on the care plan for the trauma from nails to the palm of the left hand. The absence of a documented intervention in the care plan indicates a failure to adhere to the facility's policy and to address the resident's specific care needs, particularly concerning the prevention and management of pressure injuries.
Failure to Conduct Quarterly Care Plan Conference
Penalty
Summary
The facility failed to conduct a quarterly care plan conference meeting with the resident or their family representative for one of the sampled residents. According to the facility's policy, a comprehensive care plan should be developed and reviewed by an interdisciplinary team, including family members or surrogates, after each comprehensive and quarterly Minimum Data Set (MDS) assessment. However, the facility was unable to provide documentation that such a meeting was conducted for the resident's quarterly comprehensive assessment. The resident in question was admitted with multiple diagnoses, including lack of coordination, severe protein-calorie malnutrition, diabetes, heart disease, anxiety, and depression. The quarterly MDS indicated that the resident is rarely or never understood and is dependent on staff for activities of daily living. Interviews with the Social Service Director and the Regional Director of Clinical Services confirmed that the family representative was not invited to the care plan meeting, which should have been conducted quarterly with the MDS assessment completion.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to maintain accurate medication records and reconcile controlled medications for one of the registered nurses observed during medication administration. The facility's policy on medication administration requires that controlled substances be signed out in the narcotic book after administration. However, discrepancies were found in the narcotic reconciliation records for three residents. For Resident #1, the controlled drug record indicated 10 capsules of Gabapentin remaining, but only 8 capsules were found in the narcotic card. The LPN explained that doses were administered at 8 AM and noon, but the count was not updated. Similarly, for Resident #20, the controlled drug record showed 18 tablets of Alprazolam remaining, while the narcotic card had only 16 tablets. The LPN stated that doses were given at 8 AM and noon, but the narcotic book was not updated. For Resident #48, the controlled drug record indicated 11 tablets of Hydrocodone/Acetaminophen remaining, but only 10 tablets were found. The LPN admitted to administering a dose at 8 AM without updating the narcotic book. The Interim Director of Nursing confirmed that narcotics should be signed out in the narcotics book immediately after administration, indicating a failure to adhere to the facility's medication administration policy.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as evidenced by the presence of expired medications and improper storage of over-the-counter medication. During an observation in the Medication Room, eight expired Humalog Solution 100 UNIT/ML Pens were found with a use-by date of 12/19/24. The Assistant Director of Nursing confirmed that expired medications should not be present in the medication room. Additionally, an over-the-counter medication for muscle cramps was observed in a shared bathroom used by two residents. The Interim Director of Nursing confirmed that over-the-counter medications should not be stored in the bathroom.
Infection Control Breach During Ostomy Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during ostomy care, as observed with a Licensed Practical Nurse (LPN) identified as LPN E. The facility's hand hygiene policy mandates that all staff perform hand hygiene procedures to prevent the spread of infection, specifically before and after handling clean or soiled dressings. During an observation, LPN E was seen performing ostomy care for a resident without changing gloves and washing hands after cleaning the stoma area and before applying a new ostomy bag. This action was contrary to the facility's policy and was confirmed by LPN E during an interview. The resident involved in this incident was admitted with multiple diagnoses, including Dementia, Quadriplegia, Diabetes, and Heart Failure, and required total assistance for all activities of daily living. The resident had an ileostomy, and physician orders indicated that the ostomy bag should be changed every three days or as needed. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the proper procedure should have included changing gloves and washing hands after cleansing the stoma before applying a new pouch, which was not followed by LPN E.
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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