Wexford House
Inspection history, citations, penalties and survey trends for this long-term care facility in Kingsport, Tennessee.
- Location
- 2421 John B Dennis Highway, Kingsport, Tennessee 37660
- CMS Provider Number
- 445207
- Inspections on file
- 24
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Wexford House during CMS and state inspections, most recent first.
A facility failed to report an allegation of abuse involving a resident with cognitive capacity and complex medical needs, after staff reported that a CNA had taken unauthorized photos of the resident and allegedly sent them to the ombudsman. The resident stated she did not consent to the photos, and the DON documented the resident's concerns. Despite these reports, the Administrator did not notify the State Survey Agency as required by policy.
Staff responsible for testing dishwasher sanitizer levels lacked the necessary competency to follow manufacturer guidelines, as evidenced by the consistent documentation of a chlorine rinse result not available on the test strip guide and inability to explain or properly interpret test results.
Surveyors identified extensive sanitation failures in the kitchen, including dirty equipment, improper food storage, overflowing trash, and infrequent cleaning of the ice machine and deep fryer. Staff interviews confirmed the lack of a cleaning schedule and improper handwashing practices, with these deficiencies potentially affecting nearly all residents.
Facility staff did not consistently monitor or document resident refrigerator temperatures as required by policy, with several refrigerators found above the recommended temperature and some logs incomplete. Expired food items were also found in resident refrigerators, and staff failed to discard them as per facility guidelines. These deficiencies were confirmed by the DON during observations and interviews.
A resident with severe cognitive impairment and multiple medical conditions was found to be living in a room with missing wallpaper, peeling paint, and additional wallpaper damage, which the Maintenance Director was unaware of and acknowledged did not meet homelike standards.
A resident with a history of daily smokeless tobacco use, who was cognitively intact and had multiple medical diagnoses, did not have their tobacco use addressed in their care plan. Despite facility policy and staff acknowledgment that tobacco use should be included, the care plan was not updated to reflect this need, as confirmed by medical record review, observations, and staff interviews.
The facility did not follow its policy requiring on-site destruction of unused narcotics witnessed by appropriate staff. Instead, narcotics from discharged or deceased residents were collected and processed off-site, and key staff were unaware that this practice did not align with facility policy.
Staff did not provide required hand hygiene assistance to three residents with cognitive and physical impairments before meal service, despite facility policy mandating this practice. Observations and interviews confirmed that CNAs delivered meal trays and allowed residents to eat without offering hand hygiene, and the DON acknowledged the lapse in infection control procedures.
The facility did not maintain kitchen cooking equipment in a sanitary condition, potentially affecting 82 out of 86 residents. Observations revealed a large sheet pan with crusty, greenish-brown food debris, a hot food holding cabinet with dried, black, greasy food debris, and a plate warmer with dried, brownish-yellow residue. The undated policies on sanitizing pots, pans, and equipment were not followed.
The facility failed to maintain residents' dignity by serving milk products in disposable cartons without offering glasses and by having a CNA feed a resident while standing over them. Interviews revealed a lack of awareness regarding regulations for non-disposable dishware, and the practice of serving milk in cartons was routine without resident requests.
The facility failed to accurately complete MDS assessments for two residents. One resident's admission MDS did not list Quadriplegia as an active diagnosis despite being dependent on staff for various activities. Another resident's quarterly MDS did not list Hypothyroidism as an active diagnosis despite receiving daily medication for the condition.
The facility failed to include a cognitively intact resident in the care planning process, despite the resident requiring substantial assistance with daily activities. The resident did not receive invitations to quarterly care plan meetings, nor a copy of the latest care plan, which was acknowledged as an oversight by the Social Services Director and confirmed by the Director of Nursing.
The facility failed to ensure expired supplies were not available for resident use in one of the three medication carts observed. An LPN found expired cotton swabs, a specimen collection swab kit, and blood draw vials in the 300 long hall medication cart. The DON confirmed these items should not have been on the cart.
The facility failed to properly contain garbage and refuse in two dumpsters, leaving them exposed to air, elements, and potential pests. The Food Service Manager confirmed that the dumpsters should have been tightly closed, as per facility policies.
Failure to Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency as required by its own policy. The policy mandates that the Abuse Coordinator, who is the Administrator, is responsible for reporting all allegations or suspicions of abuse, including mental abuse facilitated through technology, to the state survey agency. In this case, several staff members reported that a CNA had taken photos of a resident's back or wounds and sent them to the ombudsman. The resident involved, who was cognitively intact and required assistance with activities of daily living, stated that she did not give permission for any photos to be taken. The Director of Nursing documented that the resident reported photos were taken without her knowledge. The Administrator interviewed the CNA, who denied taking or sending any photos and denied using her phone in the facility. No staff reported actually seeing the photos on the CNA's or any other employee's phone. Despite the allegations and statements from staff and the resident, the Administrator did not report the incident to the State Survey Agency, stating that although it is normally done, it was not done in this instance. The ombudsman confirmed not receiving any photos or having any related discussions. The failure to report the allegation of abuse, as required by facility policy and regulation, constitutes the deficiency identified in the report.
Incompetent Staff Testing of Dishwasher Sanitizer Levels
Penalty
Summary
The facility failed to employ staff with the appropriate competencies to ensure manufacturer guidelines were followed for testing chemical sanitation in the dishwasher. Review of the Dishmachine Temperature Record for the specified month showed that chlorine rinse readings of 50 were consistently documented for all meals, despite the fact that the test strips and their guide did not include a 50 ppm reading as an option. During observation, the Certified Dietary Manager (CDM) demonstrated difficulty reading the test strips and was unsure of the correct reading, asking the surveyor for guidance and instructing a Dietary Aide to test the chemical results in a manner inconsistent with standard procedure. When questioned about how the recorded results of 50 ppm were obtained, neither the CDM nor the Dietary Aide could provide an explanation.
Widespread Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain kitchen equipment and food storage, preparation, and serving areas in a clean and sanitary condition, as required by professional standards and facility policy. Observations revealed multiple sanitation issues, including a black substance on the ice machine in contact with ice, lack of paper towels at the hand washing station, and staff using a sink designated for pots and pans to wash their hands. Numerous pieces of kitchen equipment, such as can openers, mixers, microwaves, ovens, deep fryers, and warming racks, were found with dried food debris, grease, or other contaminants. Food items were improperly stored, with undated containers, wet-nested pans, and open or unlabeled items in coolers and freezers. Trash cans in food preparation areas were uncovered, overflowing, and in contact with clean storage containers. Additionally, maintenance records showed the ice machine was only cleaned twice a year, and the deep fryer was cleaned about every six months. Interviews with dietary staff and the Registered Dietician confirmed the absence of a cleaning schedule and acknowledged that the kitchen was not maintained in a sanitary condition. The Maintenance Director verified the infrequent cleaning of the ice machine. These deficiencies had the potential to affect 80 of 81 residents, as the unsanitary conditions could compromise the safety and quality of food served to residents.
Failure to Monitor Resident Refrigerator Temperatures and Remove Expired Foods
Penalty
Summary
The facility failed to adhere to its policy regarding the monitoring and maintenance of resident personal refrigerators, as well as the management of food items stored within them. Observations revealed that temperature logs for several residents' refrigerators were incomplete, with missing daily recordings on specific dates. Additionally, recorded temperatures frequently exceeded the facility's policy requirement of maintaining refrigerator temperatures below 41°F, with some logs showing temperatures as high as 44°F and 60°F. In one instance, a thermometer inside a resident's refrigerator displayed a temperature of 73°F. These lapses were confirmed during interviews and observations. Further deficiencies were noted in the handling of expired food items. Expired yogurt was found in the refrigerators of two residents, with expiration dates that had already passed. The facility's policy required that foods with use-by dates be discarded accordingly, but this was not consistently followed. The residents involved had various medical conditions, including dementia, hemiplegia, diabetes, chronic kidney disease, and other significant diagnoses. The DON confirmed that the facility did not ensure daily monitoring and documentation of refrigerator temperatures, did not maintain required temperature levels, and did not consistently discard expired foods as per policy.
Failure to Maintain Homelike Resident Room Environment
Penalty
Summary
The facility failed to provide a homelike environment for one resident who was admitted with diagnoses including hemiplegia, dysphagia, and intracranial injury, and who was noted to be severely impaired in cognitive skills for daily decision making. Observations in the resident's room revealed a large piece of wallpaper missing from the wall beside the bed, a large area of missing paint near the head of the bed, and wallpaper peeling away from the baseboard by the window. During an interview, the Maintenance Director stated he was not aware of these issues and confirmed that the room was not consistent with a homelike environment and required repairs.
Failure to Address Tobacco Use in Resident Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan addressing tobacco use for a resident who was cognitively intact and used smokeless (chewing) tobacco daily. Despite the facility's policy requiring comprehensive assessments and care plans that include all resident needs, preferences, and treatments, the resident's ongoing use of smokeless tobacco was not incorporated into their care plan. Medical record reviews confirmed the resident's tobacco use, and observations over several days showed the resident keeping and using smokeless tobacco in their room. Interviews with staff, including an LPN and the DON, confirmed that the resident's tobacco use was known and that such information should be included in the care plan. However, the care plan had not been updated to reflect this aspect of the resident's care, despite clear evidence from assessments, observations, and staff interviews that the resident regularly used smokeless tobacco.
Failure to Follow Policy for On-Site Destruction of Narcotics
Penalty
Summary
The facility failed to follow its own policy regarding the destruction of unused narcotics. According to the facility's undated policy, the destruction of drugs must be conducted on the premises and witnessed by the consultant pharmacist along with either an agent of the State Board of Pharmacy, the facility administrator, or the director of nursing services. However, review of the Narcotic Destruction Logs revealed that while the logs listed residents' names, medications, amounts of narcotics remaining, nurses' initials, and reasons for destruction, they did not document the actual destruction of the narcotics as required by policy. Interviews with the Assistant Director of Nurses (ADON), the Administrator, and the Consultant Pharmacist confirmed that narcotics belonging to residents who had expired or been discharged were not destroyed on the facility premises. Instead, a collection process was used, and the drugs were processed off-site. Both the ADON and the Administrator were unaware that the facility's practice did not align with its written policy, and the Consultant Pharmacist was also not aware of the discrepancy between the policy and the actual process for narcotic destruction.
Failure to Provide Hand Hygiene Assistance During Meal Service
Penalty
Summary
During meal service, staff failed to follow proper infection control practices related to hand hygiene for three residents who required assistance with activities of daily living (ADLs), including personal hygiene. Facility policy required staff to perform hand hygiene before and after eating, but observations revealed that staff did not offer or provide hand hygiene assistance to these residents prior to their lunch meals. Specifically, staff brought meal trays, opened silverware, and allowed residents to begin eating without ensuring hand hygiene was performed. The residents involved had significant medical conditions and cognitive impairments, including pelvis fracture, chronic kidney disease, anemia, diabetes, anxiety, weakness, hemiplegia, chronic respiratory failure, and heart failure. Their care plans and Minimum Data Set (MDS) assessments indicated they were dependent on staff for personal hygiene. Interviews with staff and the Director of Nursing confirmed that hand hygiene assistance was not provided as required by facility policy during the observed meal service.
Sanitation Issues with Kitchen Cooking Equipment
Penalty
Summary
The facility failed to ensure kitchen cooking equipment was maintained in a sanitary condition, potentially affecting 82 out of 86 residents. The undated policies on sanitizing pots and pans and equipment were not followed, as evidenced by observations on 3/18/2024. A large sheet pan had crusty, greenish-brown food debris, the hot food holding cabinet had dried, black, greasy food debris, and the plate warmer had dried, brownish-yellow residue.
Failure to Maintain Resident Dignity in Meal Service and Feeding Assistance
Penalty
Summary
The facility failed to ensure staff maintained residents' dignity by serving milk products in disposable cartons without offering glasses to nine residents across three of five hallways observed for meal tray distribution. The facility's policy on patient/resident rights and dining experience emphasized the importance of dignified and courteous treatment, yet this was not upheld. Observations and interviews revealed that residents were routinely served milk and nutritional shakes in disposable cartons without being offered glasses, and there was no evidence in the medical records that residents had requested this practice. Several residents, including those with cognitive impairments and those who were cognitively intact, confirmed they had not requested to receive their milk in disposable cartons and were not offered glasses, although they expressed varying levels of concern about the practice. Additionally, the facility failed to maintain a resident's dignity during feeding. One resident, who was totally dependent on staff for eating due to severe cognitive impairment and physical limitations, was observed being fed by a CNA who stood over the resident rather than sitting at eye level. This practice was contrary to the facility's expectations for feeding assistance, which required staff to be seated and at eye level with the resident. The CNA admitted to standing over the resident because it was more convenient for her, indicating a disregard for the resident's dignity and the facility's policies. Interviews with the facility's administration and dietary staff revealed a lack of awareness regarding regulations related to providing non-disposable cutlery and dishware, including cups and glasses. The Administrator, Director of Nursing, and dietary staff all confirmed that milk and nutritional shakes were routinely served in disposable cartons and that glasses were only provided upon resident request. This practice was a long-standing one, and there was no evidence that the facility had considered the impact on residents' dignity or made efforts to align with regulatory requirements for a dignified dining experience.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for two residents. Resident #78, who was admitted with diagnoses including Amyotrophic Lateral Sclerosis (ALS) and Quadriplegia, had an admission MDS that did not list Quadriplegia as an active diagnosis. This was despite the resident being dependent on staff for personal hygiene, dressing, transfers, and bed mobility, and the comprehensive care plan noting the risk for limitations in range of motion related to Quadriplegia. The Director of Nursing confirmed that the admission MDS assessment for Resident #78 was not accurate and did not reflect the resident's active diagnosis of Quadriplegia upon admission. Similarly, Resident #56, who was admitted with diagnoses including Adult Failure to Thrive, Hypothyroidism, Alzheimer's Dementia, and Major Depressive Disorder, had a quarterly MDS assessment that did not list Hypothyroidism as an active diagnosis. This was despite the resident having a physician's order for Levothyroxine and receiving the medication daily, as noted in the Medication Administration Record (MAR). The MDS Coordinator confirmed that Resident #56's quarterly MDS assessment was coded incorrectly and did not include the active diagnosis of Hypothyroidism.
Failure to Include Cognitively Intact Resident in Care Planning Process
Penalty
Summary
The facility failed to include Resident #31 in the care planning process, despite the resident being cognitively intact and requiring substantial assistance with daily activities. The facility's policy mandates that residents and their families be informed and invited to care plan meetings, with documentation of these attempts. However, Resident #31 did not receive invitations to the quarterly care plan meetings, nor did she receive a copy of the latest care plan. The Social Services Director (SSD) admitted that the resident was not invited to the meetings and had no documentation to show that the resident did not want to participate. Resident #31 was admitted with diagnoses including Pneumonia, Arthritis, and Diabetes Mellitus. Despite being cognitively intact, the resident was not included in the care planning process. The SSD acknowledged the oversight and confirmed that the resident had never received an invitation to or attended the quarterly care plan meetings. The Director of Nursing (DON) also confirmed that it was her expectation for cognitively intact residents to be involved in their care plan meetings, indicating a lapse in following the facility's policy.
Expired Supplies Found on Medication Cart
Penalty
Summary
The facility failed to ensure expired supplies were not available for resident use in one of the three medication carts observed. During an observation and interview with an LPN, it was found that the 300 long hall medication cart contained expired supplies, including a package of two cotton swabs, a specimen collection swab kit, three vacuum blood draw vials, and one blood draw vial. The LPN acknowledged the presence of the expired supplies and stated that the protocol was to remove such items and notify the supervisor. The Director of Nursing confirmed that the expired supplies should not have been on the medication cart.
Improper Containment of Garbage and Refuse
Penalty
Summary
The facility failed to ensure garbage and refuse were properly contained in two dumpsters. During an observation, it was noted that the hard, plastic roof covering dumpster #1 was open, and dumpster #2's sliding door on the right side was also open. This left the contents of both dumpsters exposed to air, elements, and potential pests. The Food Service Manager confirmed that the dumpsters should have been tightly closed to prevent exposure to elements and potential rodents, as per the facility's policies on garbage and trash cans and maintaining a home-like environment.
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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