Perry County Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Linden, Tennessee.
- Location
- 127 E Brooklyn Avenue, Linden, Tennessee 37096
- CMS Provider Number
- 445503
- Inspections on file
- 18
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Perry County Nursing Home during CMS and state inspections, most recent first.
Incomplete Smoking Assessments for Tobacco-Using Residents: The facility failed to complete smoking assessments with each quarterly or comprehensive MDS for several residents who used tobacco. Records showed that residents with diagnoses including HTN, AKF, dysphagia, epilepsy, heart disease, nicotine dependence, MDD, anxiety, COPD, and DM2 had prior smoking evaluations, but later quarterly MDS assessments either did not assess tobacco use or lacked updated smoking documentation. The DON stated smoking assessments should be completed on admit, quarterly, and with a change of condition.
The facility failed to maintain sanitary food storage conditions, with a kitchen vent hood covered in dust and grease, and nourishment refrigerators containing dead pests and improperly labeled or expired food items. The Certified Dietary Manager was unsure of the cleaning schedule, and the DON confirmed the improper storage practices.
A long-term care facility was found deficient in infection control practices. A CNA provided perineal care without PPE to a resident with an open lesion and catheter. Another CNA exited a room wearing PPE and failed to perform hand hygiene after removing it. A Wound Nurse did not wash hands between glove changes during wound care for a resident with a pressure ulcer. The DON confirmed the need for proper hand hygiene and PPE use.
The facility did not review resident rights during council meetings for five cognitively intact residents, despite policy requirements. The residents, who had various medical conditions, expressed concerns about this oversight, which was confirmed by the Activity Director.
A facility failed to report an incident of resident-to-resident abuse in which a cognitively intact resident reported being hit by another resident with a history of mental health issues. Despite the facility's policy requiring such incidents to be reported to authorities, the altercation was not reported within the required timeframe, and the Administrator had not fully investigated the incident.
The facility failed to investigate an allegation of resident-to-resident abuse involving two residents. Despite the facility's policy requiring immediate investigation and reporting, the incident was not reported to the administrator until several days later. A CNA was aware of the altercation but did not report it, leading to a delay in investigation. One resident was moderately cognitively impaired, while the other was cognitively intact.
A resident with multiple diagnoses developed a pressure ulcer that was incorrectly staged as Stage 3 despite being 90% covered with slough, making it unstageable. The facility failed to notify the responsible party of the wound's deterioration, contrary to its policy requiring timely communication of significant changes in resident status.
The facility failed to secure hazardous items, leaving sharps and personal care products accessible in resident rooms and an unsecured shower room. A resident with cognitive impairment had mouthwash left unattended, while another resident's room contained nail clippers and aerosol spray. The shower room was found open with razors and other hazardous items accessible. Staff confirmed these items should have been secured.
The facility failed to ensure proper labeling of enteral feeding and flush bags for two residents with PEG tubes. Both residents, who were severely cognitively impaired and dependent on staff for care, had unlabeled feeding and flush bags in their rooms. The DON confirmed that labeling with the resident's name, date, formula, and time is required.
The facility failed to follow physician orders for oxygen administration and did not maintain clean oxygen concentrators for two residents. One resident received oxygen at 3L/min instead of the ordered 2L/min, and their concentrator was dusty. Another resident received oxygen at 4L/min instead of the ordered 2L/min. The DON confirmed the discrepancies and was unsure about cleaning responsibilities.
The facility failed to properly store and secure medications, as an LPN left eye drops unattended in a resident's room, and another resident with severe cognitive impairment had unsecured antacids in their bathroom. Both incidents were confirmed by staff, highlighting a breach in medication security protocols.
Incomplete Smoking Assessments for Tobacco-Using Residents
Penalty
Summary
The facility failed to complete smoking assessments for residents who used tobacco with each quarterly or comprehensive MDS assessment. Facility policy titled, Resident Smoking, stated that all residents would be asked about tobacco use during admission and during each quarterly or comprehensive MDS assessment, and that residents who smoke would be further assessed using the Resident Safe Smoking Assessment to determine whether supervision was required or whether the resident was safe to smoke at all. The facility list of resident tobacco users identified 15 residents who smoked, 7 who vaped, and 2 who dipped or chewed. Review of the records for four sampled residents showed missing or incomplete smoking assessments after prior completed evaluations. Resident #16 had diagnoses including hypertension, acute kidney failure, dysphagia, and epilepsy; a smoking safety evaluation on 3/21/2025 indicated tobacco use and that supervision would be required during designated smoking times, but no later smoking evaluations or assessments were provided. Resident #25 had diagnoses including heart disease, nicotine dependence, major depressive disorder, cognitive communication deficit, and generalized anxiety; the last smoking assessment provided was 3/29/2024, and later quarterly MDS assessments noted tobacco use but did not include smoking assessment documentation. Resident #37 had diagnoses including essential hypertension, tobacco use, and COPD; a smoking safety evaluation on 12/19/2025 indicated tobacco use, but no later smoking evaluations or assessments were provided. Resident #65 had diagnoses including major depressive disorder, generalized anxiety disorder, nicotine dependence, and type 2 diabetes. Smoking assessment tools were completed on 3/28/2024, 3/29/2025, and 3/26/2026, but the facility was unable to provide quarterly smoking evaluations and/or assessments between those dates, and quarterly MDS assessments did not assess tobacco use. The DON stated that smoking assessments should be completed on admission, quarterly, and with a change of condition, and stated that not having an up-to-date smoking assessment could create an opportunity for risk.
Unsanitary Food Storage Conditions in Facility
Penalty
Summary
The facility failed to ensure food was stored under sanitary conditions, as observed in multiple areas. In the kitchen, the vent hood above the stove was found to have a buildup of dust and grease, indicating a lack of regular cleaning. The Certified Dietary Manager was unable to confirm the frequency of cleaning or identify who was responsible for this task. This lack of clarity and oversight contributed to the unsanitary conditions observed. Additionally, the nourishment refrigerators in the West Hall, North Hall, and East Hall were found to contain dead pests, such as gnats, and various food items that were opened, undated, unlabeled, and expired. These included items like ketchup, ranch dressing, a breakfast sandwich, and a Jell-O cup, among others. The East Hall refrigerator also lacked a thermometer, which is essential for monitoring proper storage temperatures. The Director of Nursing confirmed that food items should not be stored in such conditions, highlighting a failure in maintaining food safety standards.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain infection prevention and control practices, as evidenced by several observations involving staff members. A Certified Nursing Assistant (CNA) was observed administering perineal care to a resident with an open lesion and an indwelling urinary catheter without using Personal Protective Equipment (PPE). This resident, who was severely cognitively impaired, required enhanced barrier precautions due to their medical conditions, including impaired skin integrity and the presence of an indwelling catheter. Another incident involved a CNA who exited a resident's room while still wearing PPE to retrieve a urinal, and upon returning, removed the PPE without performing hand hygiene. This CNA, along with another, assisted the resident to a wheelchair and proceeded to weigh the resident without washing or sanitizing their hands after removing PPE. This resident also had significant medical needs, including severe cognitive impairment and reliance on staff for activities of daily living. Additionally, the Wound Nurse was observed failing to perform hand hygiene between glove changes during wound care for a resident with a Stage 3 pressure ulcer. The nurse changed gloves multiple times without washing or sanitizing hands, which is against the facility's hand hygiene policy. The Director of Nursing confirmed that staff should perform hand hygiene after removing gloves and before donning new ones, and that PPE should not be worn outside of resident rooms.
Failure to Review Resident Rights During Council Meetings
Penalty
Summary
The facility failed to ensure that resident rights were reviewed during resident council meetings for five residents who were in attendance. The facility's policy, dated September 2024, mandates that residents be informed of their rights both orally and in writing in a language they understand. However, a review of the Resident Council Minutes from August 2024 through November 2024 revealed no documentation that resident rights had been reviewed with the residents during these meetings. This oversight was confirmed during an interview with the Activity Director, who acknowledged that resident rights were not reviewed during the council meetings. The deficiency involved five residents, all of whom were cognitively intact as indicated by their BIMS scores of 15. These residents had various medical conditions, including Chronic Obstructive Pulmonary Disease, Anemia, Anxiety, Kidney Failure, Parkinsonism, Dysphagia, Atrial Fibrillation, Heart Failure, Depression, and Diabetes. During a resident council meeting, these residents expressed concerns about the lack of review of their rights, highlighting a gap in the facility's adherence to its own policy regarding resident rights communication.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse involving two residents. According to the facility's policy on abuse, neglect, and exploitation, any suspected abuse must be reported to the State Agency and the local Ombudsman office. However, the facility did not adhere to this policy. Resident #32 reported that Resident #18 followed him into the bathroom and began hitting him on the head. Despite Resident #32 informing a nurse about the incident, the facility did not report the altercation within the required 24-hour timeframe. Resident #18, who has a history of paranoid schizophrenia and other mental health issues, was moderately cognitively impaired at the time of the incident. Resident #32, who is cognitively intact, confirmed the physical altercation during an interview with the survey team. The Administrator was informed of the incident by the survey team and acknowledged the date of the incident. However, the Administrator had not spoken with the nurse assigned to Resident #32 and initially reported that there was no physical contact. The facility lacked documentation to confirm that the incident was reported as required, leading to a deficiency in reporting suspected abuse.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of resident-to-resident abuse involving two residents. According to the facility's policy on abuse, neglect, and exploitation, any suspicions or reports of abuse require an immediate investigation, which includes obtaining witness statements and reporting the incident to the facility administrator and the State Survey Agency within two hours. However, the facility did not adhere to this policy. The incident occurred on 11/26/2024, but the administrator was not notified until 12/9/2024, indicating a significant delay in reporting and investigating the incident. Resident #18, who was moderately cognitively impaired with a BIMS score of 10, and Resident #32, who was cognitively intact with a BIMS score of 15, were involved in the altercation. Despite the awareness of a Certified Nursing Assistant (CNA) about the incident, it was not reported to the charge nurse or the abuse coordinator, leading to a failure in timely and thorough investigation. The facility's inaction in addressing the incident promptly and according to policy resulted in a deficiency in handling allegations of abuse.
Failure to Properly Stage Pressure Ulcer and Notify Responsible Parties
Penalty
Summary
The facility failed to correctly identify and stage a pressure ulcer for a resident, leading to a deficiency in care. The resident, who was admitted with diagnoses including Alzheimer's Disease, Parkinson's Disease, Osteoarthritis, Dementia, and Hemiplegia/Hemiparesis, developed a pressure ulcer that was initially documented as a Stage 2 on the right buttock. However, subsequent evaluations revealed a decline to a Stage 3 pressure ulcer on the coccyx, with significant slough covering the wound bed, making it unstageable. Despite this, the wound was incorrectly documented as Stage 3, and the responsible party was not notified of the change in the wound's status. The facility's policy required timely notification of significant changes in a resident's condition to the medical staff and family, which was not adhered to in this case. The Wound Nurse confirmed that the wound was 90% covered with slough, obscuring the wound bed and preventing accurate depth measurement, which should have led to the wound being classified as unstageable. The failure to notify the physician and family representative of the wound's deterioration and the incorrect staging of the wound were confirmed during interviews with the Wound Nurse and Wound Care Specialist.
Failure to Secure Hazardous Items in Resident Rooms and Shower Room
Penalty
Summary
The facility failed to ensure residents were free from accident hazards, as evidenced by the presence of sharps and hazardous personal items in resident-occupied rooms and an unsecured shower room. In Resident #19's room, a plastic basket on the bedside table contained an 18 oz container of mouthwash, a pair of silver nail clippers, and a 4 oz can of aerosol body spray. Resident #19, who was cognitively intact but required assistance for daily living activities, was exposed to these hazards. Similarly, Resident #56, who was severely cognitively impaired and required assistance with activities of daily living, had a large 32-ounce bottle of mouthwash left unattended on the bathroom sink. Additionally, the East Hall Shower Room was found unsecured and unattended, with the door and storage cabinet left open. This allowed access to hazardous items, including disposable razors, aerosol spray deodorant, shaving cream, aerosol hair spray, and shampoo. Interviews with staff, including LPNs and the Maintenance Director, confirmed that these items should have been secured, and the shower room should have been locked at all times. The Director of Nursing also confirmed that all sharps and hazardous items should not be left unattended and unsecured in residents' rooms.
Failure to Label Enteral Feeding and Flush Bags
Penalty
Summary
The facility failed to provide proper care and services for residents with percutaneous endoscopic gastrostomy (PEG) tubes by not ensuring that enteral feeding and flush solutions were properly labeled. Resident #51, who was admitted with diagnoses including Dementia, Dysphagia, and Anorexia, was dependent on staff for all care and required tube feeding due to inadequate oral intake and a history of weight loss. Observations revealed that the enteral feeding bag and automatic flush water bag in Resident #51's room were not labeled with the date, rate of delivery, or staff initials, which was confirmed by the Director of Nursing (DON) as a requirement. Similarly, Resident #59, who was admitted with diagnoses including Senile Degeneration, Bipolar Disorder, and Dementia, was also dependent on staff for eating and required tube feeding due to swallowing problems and weight loss. Observations in Resident #59's room showed that the enteral feeding and flush bags were not labeled with the resident's name, date, time, or staff initials. The DON confirmed that staff should label the bags with the resident's name, date, formula, and the time it was hung. The facility's failure to ensure proper labeling of enteral feeding and flush bags for these residents was identified as a deficiency.
Failure to Follow Oxygen Orders and Maintain Equipment Cleanliness
Penalty
Summary
The facility failed to adhere to physician orders for oxygen administration and did not ensure the cleanliness of oxygen concentrators for two residents. Resident #29, who was admitted with chronic respiratory failure, asthma, tracheostomy status, and congestive heart failure, was observed receiving oxygen at 3L/min through a tracheostomy collar, contrary to the physician's order of 2L/min. Additionally, the oxygen concentrator in Resident #29's room was found to be dusty and covered with white residue. The Director of Nursing (DON) confirmed the incorrect oxygen setting and was unsure about the responsibility for cleaning the concentrators and filters. Resident #40, admitted with pneumonia and dependent on supplemental oxygen, was observed receiving oxygen at 4L/min, despite the physician's order for 2L/min. This discrepancy was confirmed by LPN G during an observation. The DON acknowledged that staff should follow physician orders for oxygen use. These findings indicate a failure in following prescribed oxygen therapy protocols and maintaining equipment cleanliness, as per the facility's policy.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure medications were properly stored and secured, as evidenced by two separate incidents involving medication administration and storage. During a medication pass, an LPN left eye drops unsecured and unattended on a resident's over-the-bed table while exiting the room to obtain gloves. The resident, who had moderate cognitive impairment and required assistance with daily living activities, was left with the medication unattended until the LPN returned to administer the eye drops. In another incident, a resident with severe cognitive impairment and confusion was found to have an open, undated, and unsecured bottle of antacids on the bathroom sink in their room. The resident was not capable of self-administering medication, and the presence of the unsecured medication was confirmed by two LPNs and the Director of Nursing, all of whom acknowledged that medications should not be left unattended in a resident's room.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
