TOWNE SQUARE CARE OF PURYEAR
For profit - Corporation
32 Beds
Independent
Data: November 2025
Trust Grade
43/100
#295 of 298 in TN
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Towne Square Care of Puryear has received a Trust Grade of D, which indicates below-average performance with some notable concerns. Ranking #295 out of 298 facilities in Tennessee places them in the bottom half of the state, and they are last in Henry County. The facility is worsening, with issues increasing from 5 in 2024 to 8 in 2025. While staffing turnover is impressively low at 0%, indicating that staff members stay long-term, the facility has a poor overall star rating of 1 out of 5, and $5,244 in fines raises red flags about compliance issues. There are serious sanitation concerns, including a dirty ice machine and unsanitary conditions in the kitchen, as well as a failure to provide residents with crucial information regarding the costs of discontinued therapy services, which could affect their care decisions.
- Trust Score
- D
- In Tennessee
- #295/298
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ⚠ Watch
- $5,244 in fines. Higher than 78% of Tennessee facilities, suggesting repeated compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 36 minutes of Registered Nurse (RN) attention daily — about average for Tennessee. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 19 deficiencies on record. Higher than average. Multiple issues found across inspections.
43/100
Bottom 2%
No red flags
5 → 8 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 5 issues
2025: 8 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Tennessee average (2.8)
Significant quality concerns identified by CMS
Federal Fines: $5,244
Below median ($33,413)
Minor penalties assessed
The Ugly 19 deficiencies on record
Mar 2025
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to develop am elopement risk care plan for 1 o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to develop am elopement risk care plan for 1 of 12 (Resident #4) sampled residents reviewed for care plans.
The findings include:
1. Review of the facility policy titled, .Care Planning, dated 2/1/2017, revealed .To ensure all residents have a care plan developed, implemented, revised/updated based on the needs they have .Care plans will be initiate .and updated and/or revised .with any changes that occur throughout their stay .
2. Review of the medical record review revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Impulse Disorder, Paranoid Schizophrenia, Dementia, and Anxiety.
Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 11, meaning Resident #4 had moderate cognitive impairment.
Review of the Care Plan dated 12/29/2024, revealed there were no focus/problems or interventions on the care plan related to elopement.
Review of a Nurses Note dated 2/2/2025, revealed .Heard the front door alarm going off. Resident was outside rolling in the parking lot. Assisted back inside .
Review of an Incident Report dated 2/2/2025, revealed .It was reported that resident was found outside the facility in the parking lot in her wheelchair. Resident stated that she was trying to get home .
The facility failed to develop a care plan to address elopement after Resident #4 eloped on 2/2/2025.
During an interview on 3/25/2025 at 10:24 AM, the Director of Nursing (DON) was asked when Resident #4 exited the building, did that make her an elopement risk. The DON stated, Yes. If Resident #4 is an elopement risk, should she be care planned for elopements with interventions to prevent her from leaving the building again. The DON stated, Yes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, named Hospice agreement review, medical record review, and interview, the facility failed to provide a c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, named Hospice agreement review, medical record review, and interview, the facility failed to provide a communication process, including how the communication will be documented between the Long-term Care facility and the hospice provider to ensure resident needs are addressed and met for 1 of 12 (Resident #7) sampled residents and failed to follow Physician Orders for 1 of 12 (Resident #16) sampled residents.
The findings:
1. Review of the facility policy titled, Policy & Procedure: Hospice Services, dated 2/1/2017, revealed .It is the policy of the facility to provide collaborative care with Hospice providers to ensure that our resident's end of life preferences and choices are honored .Communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met .
2. Review of the named Nursing Facility Hospice Agreement, dated July 2017, revealed .Manner of Communication .All communications between the Hospice and Nursing Facility pertaining to the care and services provided to the Resident Patient shall be documented in the Resident Patient's clinical record .Patient Care Information Provided. Hospice shall provide the Nursing Facility Designee with the following:
(a) A copy of the most recent Plan of Care specific to each Resident Patient .
(b) A copy of the Hospice election form and any advance directives specific to each Patient Resident .
(c) A copy of the physician certification and recertification of the terminal illness for each Resident Patient .
(d) Names and contact information for Hospice personnel involved in the hospice care of each Resident Patient .
(e) Instructions on how to access the Hospice's 24 hour on call system .
(f) A copy of Hospice medication information specific to each Resident Patient .
(g) A copy of Hospice physician and Attending Physician orders specific to each Resident Patient. Copies of all physician orders provided to the Nursing Facility will be in writing .Hospice will maintain adequate records of all physician orders communicated in connection with the Plan of Care .
Review of the facility policy titled, Physician Orders, dated 2/1/2017, revealed .To provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards .
3. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Encephalopathy, Chronic Obstructive Pulmonary Disease, and Pulmonary Edema.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated Resident #7 was moderately cognitively impaired.
Review of the Physician's orders dated 3/14/2025, revealed . ADMIT PATIENT TO [NAMED HOSPICE] PER FAMILY REQUEST .
Review of the significant change MDS dated [DATE], revealed a BIMS score of 6, which indicated Resident #7 was severely cognitively impaired. Resident #7 was assessed for Hospice.
Review of Nurse's Notes dated 3/15/2025, revealed .[Named Hospice] here to admit resident. Hospice DX [diagnosis]: Hypertensive heart disease with heart failure and chronic kidney disease. New orders .
During an interview on 3/25/2025 at 9:41 AM, the Director of Nursing (DON) was asked how the facility communicates with Hospice. The DON replied, They come into the facility. If they have orders, they tell us, and we put them in the chart. The DON was asked if the facility had a hospice book or somewhere for hospice to document their visits and notes. The DON replied, No.
4. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Aphasia, Contracture of Left Hand, and Cerebral Infarction.
Review of the facility's Order Summary Report dated 2/28/2025, revealed .OBTAIN ROUTINE LABS: CBC [a blood test that measure types of cells in the blood] & CMP [a blood test that measure different substances in the blood and medical conditions] Q [every] 6 MONTHS (FEBRUARY/AUGUST) OBTAIN ROUTINE HGBA1C [hemoglobin, a blood test that measures the blood sugar in the blood] q4 months (January/April/August) OBTAIN ROUTINE KEPPRA LEVEL [a blood test that measures the amount of anticonvulsant medication in the blood] Q3 MONTHS (FEBRUARY/MAY/AUGUST/NOVEMBER) .Order Date .12/1/2023 .
Review of the quarterly MDS assessment, dated 3/13/2025, revealed Resident #16 had a BIMS score of 15, indicating the Resident was cognitively intact and the use of anticoagulant, diuretic, hypoglycemic and anticonvulsant medications.
Review of the Care Plan dated 3/25/2025, revealed .I am on diuretic therapy .I have Diabetes Mellitus .I have hypertension .
Review of the medical record revealed Resident #16 had not received any labs drawn since her admission on [DATE].
During an interview on 3/25/2025 at 4:05 PM, the DON was asked for the lab results since Resident #16's admission on [DATE]. The DON stated, We don't have any .labs .
During an interview on 3/26/2025 at 7:53 AM, the DON confirmed that the lab dated 4/11/2024 was the only lab that she had for Resident #16. The DON confirmed that nursing staff should follow physician orders and the lab should have been drawn in January and February 2025 for Resident #16.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe and secure envir...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe and secure environment when hazards items were found in 2 of 18 (Resident #18 and #22) resident rooms reviewed for accidents.
The findings included:
1. Review of the facility's policy titled, Resident Rooms, dated 2/1/2017, revealed .To ensure residents are provided a clean room and environment and free of hazards .
2. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses including Diabetes, Asthma, and Dementia.
Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #18 had a Brief Interview for Mental Status Score (BIMS) of 15, indicating the resident was cognitively intact, and required supervision with Activities of Daily skills (ADLs).
Observations during medication administration in the resident's room on 3/24/2025 at 4:11 PM and on 3/25/2025 at 10:51 AM, revealed the following:
a. a bottle of pink nail polish, an 18 oz (ounce) bottle of Lavender Scent body lotion, a 20 oz bottle of [NAME] Shae Butter hair conditioner labeled keep out of reach of children on the dresser near the entrance door, unsecured and unattended
b. a bottle of tan nail polish, a 33 oz bottle of Skin Relief Moisturizing Lotion, a 20 oz bottle of body lotion, a 18oz bottle of [NAME] Butter lotion with Vitamin E Oil, an 8 oz bottle of Vitamin C Body Lotion all labeled keep out of reach of children
During an interview on 3/25/2025 at 11:05 AM, Licensed Practical Nurse (LPN) A was shown the items on the dresser and on the bedside table and was asked where these items should be stored. LPN A stated, They can't have these in their room, they can't have nail polish in here, I will have to ask [named Director of Nursing], I don't know if they can or not . LPN A turned and exited the room.
During an interview on 03/25/25 at 11:17 AM, the Director of Nursing confirmed that those items labeled keep out of reach of children and the nail polish should be secured and away from residents.
3. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Anxiety, Chronic Pain Syndrome, Hypertension, Gastro-Esophageal Reflux Disease (GERD), and Asthma.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #22 had a BIMS of 15, indicating the Resident was cognitively intact, and required supervision with ADLs.
Observations in Resident #22's room on 3/24/25 at 9:09 AM, and at 10:35 AM, revealed a bottle of nail polish remover and 2 bottles of nail polish on the bedside table, unsecured and unattended
During observation and interview on 3/24/25 at 10:38 AM, Licensed Practical Nurse (LPN) B was asked should the nail polish and the nail polish remover be on the bedside table unsecure and unattended. LPN B confirmed the nail polish and the nail polish remover should be stored in the locked medication cart or the medication room away from residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on policy review, daily staff posting review, and interview, the facility failed to post the total number of staff, and actual hours worked by the licensed staff responsible for resident care on...
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Based on policy review, daily staff posting review, and interview, the facility failed to post the total number of staff, and actual hours worked by the licensed staff responsible for resident care on the facility's Daily Staff Posting form for 20 of 24 sampled days.
The findings include:
1. Review of the facility policy titled, .Staffing, dated 2/1/2017, revealed .To ensure proper licensed nursing staff are provided to the residents according to regulations .Resident census will be posted daily.
2. Review of the facility's Daily Staff Posting forms dated 3/1/2025 thru 3/24/2025, revealed incomplete daily posting for the dates of 3/1/2025, 3/2/2025, 3/3/2025, 3/4/2025, 3/5/2025, 3/6/2025, 3/7/2025, 3/10/2025, 3/11/2025, 3/12/2025, 3/13/2025, 3/14/2025, 3/15/2025, 3/16/2025, 3/17/2025, 3/18/2025, 3/19/2025, 3/20/2025, 3/21/2025, and 3/24/2025.
During an interview on 3/25/2025 at 4:14 PM, the Director of Nursing (DON) was asked about the missing documentation related to the daily staff posting form. The DON confirmed there was missing documentation, and the form was not accurate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 2 (Registered Nurs...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 2 (Registered Nurse (RN) A) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 26 opportunities, resulting in a medication error rate of 7.69%.
The findings include:
1. Review of the facility's policy titled, Medication Error, revealed .All medication errors and drug reactions will be reported immediately to the Director of Nursing, the attending physician and will be documented according to established procedures .Medication error is defined as the preparation or administration of medications or biological that is not in accordance with the prescriber's orders, manufactures specifications regarding the preparation and/or administration of the medication or biological and /or accepted professional standards for medications or biological administration .All medication errors and drug reactions must be promptly reported to the Director of Nursing, attending physician, the pharmacist, the resident and/or responsible party .
2. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Anxiety, Chronic Pain Syndrome, Hypertension, Gastro-Esophageal Reflux Disease (GERD), and Asthma.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #22 had a Brief Interview for Mental Status Score (BIMS) of 15, indicating the resident was cognitively intact.
Review of a Physician's Order dated 3/17/2025 revealed .Omeprazole .20MG .for GERD .before breakfast at 0500 [5 AM].
Observation during medication administration on the Short Hall Medication Cart on 3/25/2025 at 8:46 AM, revealed RN A removed the following medications to administer to Resident #22:
a. omeprazole 20mg capsule.
b. montelukast 10mg tab.
c. propranolol 10mg tablet.
RN A knocked and entered Resident #22's room and administered the medications and exited the room and returned to the medication cart. RN A administered the Omeprazole at 8:46 AM and it should have been administered at 5:00 AM, resulting in 1 medication error.
During an interview on 3/25/2025 at 10:13 AM, RN A was asked did you administer Resident #22 an Omeprazole 20mg tablet. RN A confirmed she did administer the tablet. RN A was asked if the order said 5 AM should you have administered that tablet when it was ordered. RN A confirmed she should not have administered the tablet at 9 AM because it was due at 5 AM.
3. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Cognitive Communication Deficit, Depression, Drug Induced Myopathy, Hypertension, and Weakness.
Review of the MDS assessment dated [DATE], revealed Resident #75 had a BIMS Score of 11, indicating the resident was moderately cognitively impaired.
Review of the facility's Order Summary Report dated 2/28/2025, revealed .Folic Acid .1MG [milligram] .one time a day .
Observation during medication administration on the Long Hall Medication Cart on 3/25/2025 at 8:33 AM, revealed RN A removed the following medications to administer to Resident #75:
a. Potassium 10meq (milliequivalent) 1 tablet .
b. Folic acid 400 mcg (micrograms, 1000 mcg equals 1 mg) 2 tablets (800 mcg) .
c. Refresh eye drops .
RN A locked the medication cart, entered Resident #75's room and administered the medications and returned to the medication cart.
During an interview on 3/25/2025 at 9:29 AM, RN A was asked how many milligrams of folic acid Resident #75 is supposed to receive. RN A confirmed Resident #75 was supposed to receive 1mg of Folic Acid but she administered 2 -400 mcg (equaling less than 1 mg) tablets because she did not have 1mg of the Folic Acid. RN A confirmed she should not have administered the 2 tablets but should have consulted the Director of Nursing for instructions or called the physician to inform him and to receive further orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were proper...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 3 (Short Hall Medication Cart) medication storage areas was found unsecured and unattended when medications were found unsecured and unattended in 1 of 18 (Resident #22) resident occupied rooms.
The findings include:
1. Review of the facility's policy titled, Medication Storage, dated 2/1/2017, revealed .To ensure that medications and biological (biologicals) are stored in a safe, secure storage and safe handling .Compartments containing medications should be locked when not in use .Trays and carts used to transport such items should not be left unattended .
2. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Anxiety, Chronic Pain Syndrome, Hypertension, and Asthma.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #22 had a Brief Interview for Mental Status Score (BIMS) of 15, indicating the resident was cognitively intact and required moderate assistance with Activities of Daily Living skills.
Observations in Resident #22's room on 3/24/2025 at 9:09 AM and at 10:35 AM, revealed 1 bag of cough drops on the bedside table, unsecured and unattended.
During observation and interview on 3/24/2025 at 10:38 AM, Licensed Practical Nurse (LPN) B was shown the bag of cough drops on the bedside table and was asked should they be there. LPN B confirmed they should be locked on the medication cart or in the medication room and not accessible to residents. LPN B was asked does Resident #22 have a Medication Self Administration Assessment. LPN B confirmed that no resident in the facility has been assessed to self-administer medications.
3. Observation at the Nurses' Station on 3/24/2025 at 8:58 AM and at 9:00 AM, revealed the Short Hall Medication Cart was unlocked and unsecured, with no licensed nursing staff at the nurses' desk.
During an interview on 3/24/2025 at 9:05 AM, LPN B, entered the Nurses' Desk from down the Long Hall and was asked should the medication cart be left unlocked and unattended. LPN B confirmed that the medication cart should be locked at all times when not in use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on policy review, observation and interview, the facility failed to ensure proper infection control practices were followed during medication administration when 1 of 2 nurses (Licensed Practica...
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Based on policy review, observation and interview, the facility failed to ensure proper infection control practices were followed during medication administration when 1 of 2 nurses (Licensed Practical Nurse (LPN) C) picked items out of trash and failed to change gloves and/or use hand hygiene, when 1 of 1 (Registered Nurse (RN) A) failed to clean reusable resident equipment in between resident use, and when 1 of 2 (RN A) nurses administered medication to a resident after dropping the medication on the resident's person.
The findings include:
1. Review of the facility's policy titled, Hand Hygiene, dated 2/1/2017, revealed To provide guidelines to staff for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of transmission of infections .Staff will perform hand hygiene by washing hands .and should be performed under the following conditions .After handling items potentially contaminated with blood, body fluids or secretions .
Review of the facility's policy titled, Disinfecting Resident Equipment, dated 2/1/2017, revealed .To provide guidelines for disinfection in accordance with manufacturer recommendations for reusable equipment used in resident care. Reusable resident care equipment includes, but not limited to .Blood Pressure Cuff .Reusable equipment will be cleaned and disinfected after use of one resident and before use of another resident .
2. Observation during medication administration on the Long Hall Medication Cart on 3/24/25 at 4:11 PM, revealed the following LPN C donned a pair of clean gloves, began cleaning the glucometer machine and was asked what was used to clean the glucometer machine. LPN C reached into the trash can with her gloved hand and obtained the package that the cleaning cloth came out of and then continued to clean the glucometer machine with the same gloved hands. LPN C failed to change gloves and re-clean the glucometer machine after reaching into the trash can.
3. During medication administration on Long Hall Medication Cart 1 on 3/25/2025 at 8:33 AM, revealed RN A removed medication to administer to Resident #75. RN A entered the room, took the resident's blood pressure with a cuff blood pressure machine, and returned to the medication cart and placed the blood pressure cuff on top of the medication cart without cleaning or disinfecting.
During medication administration on the Short Hall Medication Cart on 3/25/2025 at 8:46 AM, revealed RN A removed medications to administer to Resident #22. RN A entered Resident #22's room, took the resident's blood pressure with the same blood pressure cuff and failed to clean or disinfect after using on Resident #75 and prior to using on Resident #22.
Observation during medication administration on the Long Hall Medication Cart on 3/25/2025 at 8:45 AM, revealed RN A removed medications for Resident #5 to be administered. RN A knocked and entered the resident's room, administered the medications, dropping one unidentified tablet on the resident's chest area, picked up the medication with her bare hands and placed it back into the medication up and administered it to Resident #5. RN A exited the room and returned to the medication cart.
During an interview on 3/25/25 at 9:21 AM, RN A confirmed that all reusable equipment should be cleaned with a sani wipe before and after each resident use and that she failed to do that in between using the blood pressure cuff on Resident #75 and #22. RN A confirmed she should have discarded the tablet she dropped on Resident #5's chest area and replaced it with another tablet and that she should not have picked it up with her bare hands.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on policy review, observation, and interview, the facility failed to maintain a sanitary kitchen when 1 of 1 ice machines was observed to have a dark slimy build up and when 1 of 1 nourishment r...
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Based on policy review, observation, and interview, the facility failed to maintain a sanitary kitchen when 1 of 1 ice machines was observed to have a dark slimy build up and when 1 of 1 nourishment refrigerator had a yellow sticky substance in the freezer and refrigerator.
The findings include:
1. The facility policy titled, Policy & Procedure: Sanitizing, dated 2/1/2017, revealed .food storage .areas will be kept clean and free from litter, debris .All equipment .shall be washed to clean and sanitize using hot water and/or chemical sanitization solution .Ice machines .will be .cleansed and sanitized .
2. Observation in the kitchen on 3/24/2025 at 8:40 AM, revealed a dark slimy build up on inside of the ice machine.
During an observation and interview on 3/24/2025 at 8:45 AM the Certified Dietary Manager (CDM) was asked if there should be a build up of dark slime in the ice machine. She stated, No .
During an interview on 3/25/2025 at 2:15 PM, the Administrator confirmed there should not be black slime in the ice machine.
3. During an observation and interview in the medication room on 3/26/2025 at 9:09 AM, revealed the nourishment refrigerator had a yellow sticky substance in the freezer and a yellow sticky substance on the 2nd shelf in the refrigerator. Registered Nurse (RN) A was asked if there should be a yellow substance in the freezer or on the refrigerator shelf below, RN A stated, .no .
Apr 2024
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, facility investigation review, and interview, the facility failed to report alleg...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, facility investigation review, and interview, the facility failed to report allegations of abuse to Adult Protection Service (APS) and Long-Term Care Ombudsman for 1 of 3 (Resident #177) sampled residents reviewed for abuse, failed to report an allegation of abuse to local law enforcement, and failed to complete a 5 day follow-up report to the state agency for 3 of 3 (Resident #8, #17, and #177) sampled residents reviewed for allegations of abuse.
The findings include:
1. Review of the policy Abuse and Neglect, dated 2/1/2017, revealed, .establish guidelines that prevents, identifies and report resident abuse and neglect .right to be free from verbal, sexual, physical, and mental abuse .any .allegation of abuse must be reported to the state agency and law enforcement .
2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses of Schizophrenia, Cognitive Communication Deficit, Dementia, and Unsteadiness on Feet.
Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #8 was severely cognitively impaired.
3. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses of Dementia, Depression, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, and Adult Failure to Thrive.
Review of the admission MDS dated [DATE], revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident was moderately cognitive impaired.
Review of the facility's Investigation Report dated 11/17/2023, revealed the Administrator was notified by phone on 11/17/2023, that Resident #17 reported that about six days earlier he had been sitting in the dining room before lunch when Resident #8 approached him and felt around the front of his chest and his hands wandered down the front of his body around his groin area.
Resident #17 was immediately assessed and no physical or mental harm could be found. Resident did display increased anxiety but when questioned stated that his sister-in-law had had hip surgery that day and he was upset about that. Resident's Representative was called to report the incident. Resident was assessed by the physician and also by the Psych Nurse Practitioner. The Psych Nurse Practitioner followed up on Resident #17 for 72 hours. Other cognitively intact residents were interviewed and no one else reported any kind of trouble with Resident #8 . The investigation concluded the allegation could not be verified due to the alleged perpetrator is severely impaired in vision and was often observed often feeling his way down the halls as he tried to find his way to where he was going. The allegation of abuse was reported to the State agency and to the Ombudsman. The Corrective Action Plan was to in-service staff on the abuse and neglect policy and to supervise the alleged perpetrator when he was in crowded areas.
Review of the facility's Incident Reporting System sheet revealed the facility did not report the allegation of abuse to the police and there was no 5 day follow up.
During an interview on 4/3/2024 at 10:07 AM, the Director of Nursing (DON) confirmed that the facility did not call and file a report with the police after the alleged altercation between Resident #8 and Resident #17 but that they had called the Ombudsman.
During an interview on 4/3/2024 at 4:12 PM, the Administrator confirmed she did not report the allegation of abuse to the police. The Administrator also confirmed that she did not conduct and report a 5 day follow up to the state.
4. Review of the medical record revealed Resident #177 was admitted the facility on 4/10/2023 with diagnoses of Cognitive Communication Deficit, Anxiety, Depression, and Heart Failure.
Review of the admission MDS dated [DATE], revealed Resident #177 had a BIMS of 8, indicating the resident was moderately cognitively impaired.
Review of the facility's Investigation Report, dated 4/30/2023, revealed the Administrator was notified by phone on 4/30/2024 that Resident #177 reported that she had been hit by a staff member on 4/29/2024. The Administrator arrived at the facility on 4/30/2023 and began an investigation that started with interviewing Resident #177. The Administrator presented staff members who fit Resident #177's description of the alleged perpetrator to Resident #177 and the resident denied all as being the person who had hit her. The Administrator completed an assessment of the resident; the resident had no physical or mental harm. The Administrator obtained statements from staff members. The Administrator interviewed other residents who may have had contact with the alleged perpetrator and were cognitively intact. The investigation concluded the allegation could not be substantiated. The allegation of abuse was reported to the state. The Corrective Action Plan was to continue to in-service and train staff on the abuse and neglect policy and to address with residents to report incidents immediately.
Review of the facility's Incident Reporting System, revealed the facility did not report the allegation of abuse to the police, APS, or the Ombudsman, and there was no 5 day follow up.
During an interview on 4/3/2024 at 3:27 PM, the Administrator was asked and confirmed she did not report the allegation of abuse to the police, the Ombudsman, or the APS. The Administrator also confirmed that she did not conduct and report a 5 day follow up to the state.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure neurological (neuro) ch...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure neurological (neuro) checks were obtained after an unwitnessed fall with a head injury for 1 of 2 (Resident #127) reviewed for accident hazards.
The findings include:
1. The facility's policy titled Neuro Assessment, dated 2/1/2017, revealed .Neurological assessment will be performed by a licensed nurse when .head injury .unwitnessed falls .Neurological Assessments should be performed .for a 72 hour period .
2. Review of the medical record revealed Resident #127 was admitted to the facility on [DATE], with diagnoses of Dementia, Osteoarthritis, History of Malignant Neoplasm of Uterus, and Left Artificial Hip Joint.
Review of the admission Minimum Data Set, dated [DATE], revealed Resident #127 was assessed with a Brief Interview for Mental Status score of 7, indicating the resident was severely cognitive impaired, assessed with inattention, disorganized thinking and Altered Level of Consciousness, Independent with indoor mobility, required the use of a walker, and was moderate to dependent on staff for activities of daily living skills, incontinent of both bowel and bladder, an active diagnosis of Non Alzheimer's Dementia, and having 1 fall with injury since admission.
Review of the Care Plan dated 3/21/2024 revealed, .I am at risk for falls r/t [related to] Confusion, Gait/balance problems .I have limited physical mobility .
Review of a Fall Incident Report, dated 3/27/2024 revealed, .4:18 AM .Incident Location .Resident's Bathroom .Heard call for help coming from resident's bathroom. Observed resident sitting in floor in doorway. Alert and responsive but noted to have small hematoma to left outer brow and skin tear dorsum of left hand .Resident Description .Resident stated she was trying to get to bathroom. She also stated she hit her head on the door facing of the bathroom .Upon assessing resident it was noted that resident had incurred a hematoma to her outer left eye brow which measured 5 cm [centimeters] x 3.75 cm .
Review of the facility's fall investigation revealed no neuro checks were included in the investigation.
Review of the medical record revealed the facility failed to provide neuro checks for Resident #127 for the fall that occurred on 3/27/2024.
Observation in Resident #127's bathroom on 4/1/24 at 12:58 PM, revealed staff assisting resident into the bathroom, resident noted to have large purple and bluish discoloring to the left side of her face.
Observation in the dining room on 4/2/24 at 8:23 AM, revealed Resident #127 sitting up in wheelchair feeding herself her breakfast meal, purple bluish discoloring remains to the left side of the resident's face.
During an interview on 4/3/24 at 9:14 AM, the Director of Nursing (DON) confirmed that Resident #127 had a fall on 3/27/2024 that resulted in bruising and a hematoma to the left side of her face. The DON was asked was neuro checks obtained as a result of her unwitnessed fall that occurred on 3/27/2024, that resulted in a hematoma and bruising to her left side of her face. The DON confirmed that she was unable to locate the neuro checks and that they should be readily accessible in the resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on policy review, nurse schedules, facility group hours report, facility time sheets, and interview, the facility failed to ensure there was a Registered Nurse (RN) on duty for 8 consecutive hou...
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Based on policy review, nurse schedules, facility group hours report, facility time sheets, and interview, the facility failed to ensure there was a Registered Nurse (RN) on duty for 8 consecutive hours a day, 7 days a week for 4 of 29 days (10/8/2023, 11/5/202, 11/11/2023, and 11/26/2023) reviewed for RN coverage.
The findings include:
Review of the facility's policy title, Staffing, dated 2/1/2017, revealed .To ensure proper licensed nursing staff are provided to the residents according to regulation .The facility shall provide a Registered Nurse for 8 consecutive hours every day .
Review of the nurse schedules from 10/2023 to 12/2023, revealed there was no RN scheduled for 10/8/2023, 11/5/2023, 11/11/2023, and 11/26/2023.
Review of the facility's Group Hours, report (punch time sheet) from 10/1/2023 thru 12/31/2023, revealed no RN punched into work indicating a RN was in the building for 8 consecutive hours on 10/8/2023, 11/5/2023, 11/11/2023, and 11/26/2023.
Review of the Director of Nurses (DON) Time Sheet from 10/2023 thru 12/31/2023 revealed, the DON did not sign into work as an RN, to provide 8 consecutive hours of RN coverage on 10/8/2023, 11/5/2023, 11/11/2023, and 11/26/2023.
During an interview on 4/3/2024 at 7:18 PM, the DON confirmed the facility should have 8 consecutive hours of RN coverage per day. The DON confirmed the facility was unable to provide documentation that an RN worked on 10/8/2023, 11/5/2023, 11/11/2023, and 11/26/2023 for 8 consecutive hours.
The facility was unable to provide documentation showing 8 consecutive hours of daily RN coverage on 10/8/2023, 11/5/2023, 11/11/2023, and 11/26/2023.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on policy review, observation, and interview, the facility failed to maintain an adequate supply of over-the-counter medications for 3 of 3 (Medication Cart #1, Medication Cart #2, and Medicatio...
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Based on policy review, observation, and interview, the facility failed to maintain an adequate supply of over-the-counter medications for 3 of 3 (Medication Cart #1, Medication Cart #2, and Medication Storage Room) medication carts reviewed for medication storage.
The findings include:
1. Review of the facility's policy titled Supply Ordering, dated 2/17/2027, revealed .any supplies needed to care for the residents will be ordered from an approved medical vendor .Designated staff .maintain all supplies in the stock room .Orders will be placed to the medical vendor at least monthly, but more if needed .supplies to be ordered include .Over-the-Counter medications .supplies needed to provide care to the residents .Supply list will be given to the Administrator and /or his/her Designee .Order will be submitted by the Administrator and/or his/her Designee .Orders that are delivered to the facility will be placed in the stock room .may choose to use a local vendor or store to procure any items that are unavailable or backordered .
Review of the facility policy titled Physician Orders, dated 2/1/2017, revealed .Medications will be ordered from the pharmacy to ensure prompt delivery .
2. Review of the [Named Supply Company] manifest order form dated 2/13/2024, revealed, .1 box of MUCINEX (medication used for coughing), TAB [tablet] 600-30MG (milligrams) .4 boxes of OMEPRAZOLE (medication used for stomach acid) TAB 20MG .
Review of the [Named Supply Company] manifest order form dated 2/26/2024, revealed, .4 boxes of MUCINEX, TAB 600MG .2 boxes of OMEPRAZOLE TAB 20MG .
Review of the [Named Supply Company] manifest order form dated 3/28/2024, revealed, .4 boxes of MUCINEX, TAB ER 600MG .
Review of the EMAR (Electronic Medication Administration Record (MAR) Progress Notes for Resident #7 revealed documentation of .medication not available at this time .on 2/19/2024 at 12:52, 2/20/2024 at 8:45 AM, 2/20/2024 at 1:26 PM, 2/21/2024 at 8:16 AM, 2/21/2024 at 1:10 PM, 2/22/2024 at 8:23 AM, 2/22/2024 at 4:25 PM, 3/27/2024 at 1:29 PM, 4/1/2024 at 1:09 PM, 4/2/2024 at 8:38 AM, and 4/2/2024 at 1:10 PM.
Review of the 2/2024 MAR revealed, Resident #7 did not receive Mucinex on 2/19/2024, 2/20/2024, 2/21/2024, and 2/22/2024.
Review of the 3/2024 MAR revealed, Resident #7 did not receive Mucinex on 3/7/2024 and 3/28/2024.
Review of the MAR dated 4/2024 revealed, Resident #7 did not receive Mucinex on 4/1/2024 and 4/2/2024.
Observation on 4/2/2024 at 8:25 AM, during medication administration, revealed the Registered Nurse (RN) had a plastic cup of medications and confirmed she was taking them to Resident #7. The RN exited Resident #7's room and stated, .everything was in the cup except for omeprazole and Mucinex because they were still waiting for them to come in .
Observation in the medication room (Medication Storage Room) on 4/2/2024 at 10:15 AM, revealed no over the counter medication stock for Mucinex ER or Omeprazole in the medication storage room.
During an interview on 4/2/2024 at 9:00 AM, the RN confirmed that the facility was out of the over the counter medication of Mucinex ER and Omeprazole. The RN was asked how long the facility had been out of the two medications. The RN stated, At least a week .
During an interview on 4/3/2024 at 8:23 AM, the RN was asked what the process is for ordering over-the-counter medications. The RN stated, .we have an order form in the drawer and fill it out .when it gets down to 1-2 boxes .seems we have been having problems getting our medications for the last month or two always put a note in [the computer] so that we know that's the reason we don't give it .Been out for about a week, gave [omeprazole] the last time on last Thursday [3/28/2024] .last week sometime for the Mucinex, not sure what day .
During an interview on 4/3/2024 at 2:47 PM, the Administrator was shown a copy of the order sheet and asked if this surveyor could see the order sheets from January till April. The Administrator stated, .I do not save those order sheets .once I order what is on the sheet, I throw it away .I'm aware that we [the Facility] do not have any [omeprazole and Mucinex] in stock at the present . The Administrator was asked is there any other means the facility had for obtaining medications when they do not come in. The Administrator stated, .Yes, we could get them at the [Named Retail Store] . The Administrator was asked should all medications including over-the-counter medications Mucinex ER and Omeprazole be available for administration for the residents. The Administrator stated, .Yes.
During a telephone interview on 4/3/2024 at 3:20 PM, the Nurse Practitioner (NP) was asked should all medications be available for administration for residents if there was a physician's order. The NP stated, .Yes.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, Job Description, observation, and interview, the facility failed to ensure food was stored, prepared, an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, Job Description, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by dirty trash can, carbon build-up on the pans, dirty equipment, the deep fryer with carbon build-up with food particles, carbon build-up on the flat grill, and large amount of greasy dark stain on the floor beside and behind the deep fryer, kitchen cabinets with large amount of peeling Formica laminate on the doors and drawer, cabinet under the sink with dark furry substance with an old stained cloth and the cabinet underneath in disrepair. The facility had a census of 25 with 25 of those residents receiving a meal tray from the kitchen.
The findings included:
1. Review of the facility's Sanitizing, policy dated 2/1/2017, revealed .The food service area shall be maintained in a clean and sanitary manner .The Dietary Manager/Food Service Manager will be responsible for creating and maintaining a regular cleaning schedule of kitchen and dining areas to prevent the accumulation of dirt, debris and grime .Kitchen .surfaces not in contact with food shall be cleaned as a part of a regular preventative maintenance schedule .
2. Review of the undated Dietary Weekly/Monthly Cleaning Schedule, revealed .Weekly Cleaning .Griddle .Convection Oven .Pots/Pan - Carbon Removal .Monthly Cleaning .Fryer - clean & [and] replace grease .Morning Dietary .Prep tables .Afternoon Dietary .Sweep & mop floors .
Review of the signed Job Description titled Director of Food Services, dated 4/3/2024, revealed .The primary purpose of your job position is to .organizing, developing and directing the overall operation of the Food Services Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility .to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner .
3. Observation in the kitchen on 4/1/2024 at 9:44 AM, 4/2/2024 at 8:06 AM, and on 4/3/2024 at 2:07 PM, with the Dietary Manager (DM) revealed the following:
A trash can lid with large amount of dark stains on the inside and outside lid.
Metal prep (prepare) table on the bottom shelf had 4 half pans with a large amount of thick carbon buildup on the outside and inside of the pans.
A metal prep table had 2 full sheet pans on the bottom shelf with a large of carbon buildup on the outside and inside of the pans.
A metal prep table had dark stain buildup on the front end of the bottom shelf.
The Convection oven had a large amount of dark dried food substance.
A deep fryer had a large sheet pan with a large amount of carbon buildup covering the fryer.
A deep fryer had a large amount of food particles inside the fryer and carbon buildup on the left side of the deep fryer.
The flat grill had a large amount of carbon buildup on the left side of the grill.
The kitchen cabinets with large amount of peeling Formica laminate on the doors and drawers.
The cabinet under the sink had a large amount of dark furry stains and an old stained washcloth on the bottom of the caved in floor of the cabinet, and the back wall had a large hole torn apart.
Observation and interview in the kitchen on 4/2/2024 at 8:06 AM, with the DM revealed on the drying rack was 3 half pans and 1 full pan with a large amount of carbon build up on the inside and outside of the pans, and a full pan with a white food substance. The DM was asked what the food substance in the corner of the full pan is, The DM stated, .A piece of French toast .
During an interview on 4/3/2024 at 11:08 AM, the DM was asked how often the deep fryers are cleaned and should there be a large amount of food particles on the on the inside of the deep fryer. The DM stated, .the cleaning list I gave you, we do our fryer monthly .of course the answer they would be no we should not have food particles in the fryer . The DM was asked should the oven have run off dripping in the bottom of the oven. The DM stated, .No .those [oven] are clean after the spills are made . The DM was asked should the sheet pans have a large amount of carbon buildup on the inside and outside of the pans. The DM stated, .No .we generally do [clean] that [carbon] once a month .I have to reeducate the staff on what to clean on those pans with .it's just been overlooked on that part of the pans . The DM was asked should the trash can at the hand sink have dark stains on the outside and inside of the lid. The DM stated, .No, the trash cans get cleaned once a month . The DM was asked should the deep fryer have carbon buildup on the sides, food particles inside, food particles on the side and behind the deep fryer and dark stains on the floor. The DM stated, .No .it's probable the grease buildup . The DM was asked should the toaster have carbon buildup. The DM stated, No. The DM was asked should the clean pans on the drying rack have food particles. The DM stated, No, ma'am. The DM was asked what the dark furry stain under the sink was and should the shelves be caved in with the back wall torn away. The DON stated, .It looks like mold .No the cabinets should not look like that .
During an interview on 4/3/2024 at 5:09 PM, the Administrator was asked should the kitchen have cabinet with the Formica laminate peeling and torn off the cabinets. That Administrator stated, .No, they need to be replaced . The Administrator was asked should the cabinet under the sink have dark [NAME] stains (mold) and the bottom of the shelf caved in and the back wall torn away from the wall. The Administrator stated, .No ma'am .
Mar 2022
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect when 2 of 5 staff members (Certified Nursing Assistant (CNA) #1 and #2) fa...
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Based on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect when 2 of 5 staff members (Certified Nursing Assistant (CNA) #1 and #2) failed to use courtesy titles during dining observations for 2 of 30 residents (Resident #10 and #14) observed, and when CNA #1 addressed Resident #5 with a title of endearment at the Nurses' Station during a random observation.
The findings include:
Review of the facility's policy titled, Policy & [and] Procedure: Resident Rights, dated 2/1/2017, revealed .to ensure each resident is treated with consideration, respect and in full recognition of his or her dignity and individuality .
Review of the facility's policy titled, Policy & Procedure: Name Preference, dated 2/1/2017, revealed .To ensure resident is addressed by the name they prefer .
Observation in the resident's room on 3/27/2022 at 12:30 PM, revealed CNA #2 stated to Resident #10, .ready to eat baby .
Observation in the Television Room on 3/27/2022 at 12:50 PM, revealed CNA #1 stated to Resident #14, .come on baby lets go eat .come on honey .
Random observation at the Nurses' Station on 3/28/2022 at 8:09 AM, revealed CNA #1 stated to Resident #5, .this way baby .
During an interview on 3/30/2022 at 9:35 AM, the Director of Nursing (DON) confirmed staff should not use terms of endearment to address residents such as honey, baby, or sweetie.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to update and revise the Care Plan for falls a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to update and revise the Care Plan for falls and the use of an antipsychotic and psychotropic medications for 3 of 15 sampled residents (Resident #20, #28, and #29) reviewed for Care Plans.
The findings include:
Review of the facility's titled policy Policy & Procedure: Comprehensive Care Plan, dated 2/1/2017, revealed .To provide interdisciplinary communication with the resident and/or legal representative for purposes of the development of an individualized comprehensive plan of care .Knowledge of ongoing care needs .Brief audit of medical record to ensure applicable care areas are addressed, such as .fall interventions documented, appropriate and timely after each fall .psychotropic medication review-diagnosis, reduction .Medications ordered .
Review of the facility's titled policy Policy & Procedure: Fall Reporting, dated 2/1/2017, revealed .To identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries .To promote a systematic approach and monitoring process for the care of residents who have fallen and/or those who are determined to be at risk .
Review of the medical record, revealed Resident #20 was admitted to the facility on [DATE] with diagnoses of Adult Failure to Thrive, Respiratory Failure, Atrial Fibrillation, Dysphagia, Psychosis, Depression, and Dementia.
Review of the Progress Notes and Incident Reports, revealed Resident #20 had falls on 1/4/2022 and 2/25/2022.
Review of the Care Plan dated 2/22/2022, revealed there were no new interventions documented on the Care Plan for the falls on 1/4/2022 and 2/25/2022.
Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses of Dementia, Atrial Fibrillation, Anemia, and Right Femur Fracture.
Review of a Physician's Order dated 11/29/2021, revealed .busPIRone [antidepressant] 10mg .by moth three times a day .
Review of a Physician's Order dated 11/29/2021 revealed .risperiDONE [an antipsychotic mediation medication used for psychotic episodes] .0.5mg .by mouth .two times day .
Review of a Physician's Order dated 2/25/2022, revealed .Mirtazapine [antidepressant medication used for depression] .75mg .by mouth .at bed time .
Review of the Care Plan last revised 3/27/2022, revealed Resident #28 was not care planned for the use of an antipsychotic or antidepressant medications.
Review of the medical record, revealed Resident #29 was admitted to the facility on [DATE] with diagnoses of Dementia, Diabetes Mellitus, Depression, and Head Injury.
Review of the Physician's Order dated 2/25/2022, revealed .QUEtiapine [an antipsychotic medication] .25mg .by mouth at bedtime .
Review of the Physician's Order dated 2/26/2022, revealed .Citalopram [an antidepressant] .by mouth one time day .DEPRESSION .
Review of the Care Plan dated 2/25/2022, revealed Resident #29 was not care planned for the use of an antipsychotic medication or antidepressants.
During an interview on 3/30/22 at 12:47 PM, the Director of Nursing (DON) stated, .medication side effects and adverse reactions should be care planned . The DON confirmed that Resident #20's falls and the interventions for the falls were not addressed on the Care Plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure care and services were ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure care and services were provided for 2 of 2 residents (Resident #19 and #26) reviewed for the use of an indwelling urinary catheter and when 1 of 1 (Certified Nursing Assistant (CNA) #1) failed to maintain infection control practices for 1 of 2 sampled residents (Resident #26) observed during indwelling urinary catheter care.
The findings include:
Review of the facility's policy titled, Catheter Care, dated 2/1/2017, revealed .Staff will maintain consistent and adequate hygiene standards for residents with an indwelling catheter in order to maintain comfort, function, and prevent infection .dispose of contaminated items .
Review of the medical record, revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of Congestive Heart Failure, Alzheimer's Disease, Neurogenic Bladder, Diabetes, and Paranoid Schizophrenia.
Review of the annual Minimum Data Set (MDS) dated [DATE] and the quarterly MDS dated [DATE], revealed Resident #19 had an indwelling urinary catheter.
Review of the Physician's Orders dated 3/3/2022, revealed there was no order for an indwelling urinary catheter or catheter care.
Review of the Treatment Administration Record (TAR) dated 2/2022, revealed there was no documentation Resident #19 received care for the indwelling urinary catheter.
Review of the medical record, revealed Resident #26 was admitted to the facility on [DATE] with diagnoses of Congestive Heart Failure, Pressure Ulcer Left Heel Stage 3, and Urinary Retention.
Review of the quarterly MDS dated [DATE], revealed Resident #26 had an indwelling urinary catheter.
Review of the Physician's Orders dated 3/3/2022, revealed there was no order for an indwelling urinary catheter or catheter care.
Review of the Treatment Administration Record (TAR) from 2/1/2022 to 2/28/2022 and 3/1/2022 to 3/30/2022, revealed there was no documentation that Resident #26 received care for the indwelling urinary catheter.
Observation in the resident's room during indwelling urinary catheter care on 3/29/2022 beginning at 9:33 AM, revealed CNA #1 performed catheter care for Resident #26 and placed the soiled wash cloths onto the bare floor next to the resident's bed. CNA #1 used a clean towel to pick up the soiled linen from the floor, exited the room, and placed the soiled linen in a hamper.
During an interview on 3/29/2022 at 1:24 PM, with the Director of Nursing (DON) confirmed there should be documentation for urinary catheter care and that there was no documentation for the catheter care. The DON further confirmed soiled linen should not be placed on the bare floor, a barrier should be used for soiled linen, and it should be placed in a plastic bag for transport out of the room.
During an interview on 3/30/2022 at 3:00 PM, the DON stated, .there was no order for the indwelling urinary catheter .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to monitor for the efficacy and the side effec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to monitor for the efficacy and the side effects of anticoagulants for 1 of 5 sampled residents (Resident #23) reviewed for unnecessary medications.
The findings include:
Review of the facility's undated policy titled, .Policy & [and] Procedure: Anticoagulant Therapy, revealed .All anticoagulant therapy requires close monitoring and it is critical that the resident is assessed for adverse drug reactions .such as bruising, bleeding gums, rectal bleeding .bloody urine .change in mental status .
Review of the medical record, revealed Resident #23 was admitted to the facility on [DATE] with diagnoses of Atrial Fibrillation, Pacemaker, and Congestive Heart Failure.
Review of the Physician's Order dated 2/18/2022, revealed .Coumadin [an anticoagulant-a medication used to thin the blood] .2.5mg [milligrams] and Coumadin 4 mg tablet .by mouth at bedtime every other day .
Review of the Medication Administration Record (MAR) for 1/2022, 2/2022, and 3/2022, revealed the facility failed to monitor Resident #23 for the signs and symptoms of side effects and adverse reactions for the use of an anticoagulant.
During an interview on 3/30/2022 at 12:47 PM, the Director of Nursing (DON) stated, .nurses should be monitoring for the side effects .adverse reactions .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to monitor for the efficacy and the side effec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to monitor for the efficacy and the side effects of antipsychotics and antidepressants for 2 of 5 sampled residents (Resident #28 and #29) reviewed for unnecessary medications.
The findings include:
Review of the facility's policy titled, Anti-Psychotic Drug Use, dated 2/1/2017, revealed .After implementation .behavior/symptom and medication side-effects will be monitored and documented .
Review of the facility's policy titled, .Psychotropic Medications, dated 2/1/2017, revealed .To ensure psychotropic medications (anti-depressants .) ordered for residents are monitored for appropriate use, doses, and side effects .The resident will be monitored for side effects or adverse reactions of these medications .
Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses of Dementia, Atrial Fibrillation, Anemia, and Right Femur Fracture.
Review of a Physician's Order dated 11/29/2021, revealed .busPIRone [antidepressant] 10mg [milligrams] .by moth three times a day .
Review of a Physician's Order dated 11/29/2021 revealed .risperiDONE [an antipsychotic medication used for psychotic episodes] .0.5mg .by mouth .two times day .
Review of a Physician's Order dated 2/25/2022, revealed .Mirtazapine [antidepressant medication used for depression] .75mg .by mouth .at bed time .
Review of the Medication Administration Record (MAR) for 1/2022, 2/2022, and 3/2022, revealed Resident #28 received 2 antidepressants and an antipsychotic daily from 1/1/2022 to 3/30/2022, and there was no monitoring for side effects or adverse reactions.
Review of the medical record, revealed Resident #29 was admitted to the facility on [DATE] with diagnoses of Dementia, Diabetes Mellitus, Depression, and Head Injury.
Review of the Physician's Order dated 2/25/2022, revealed .QUEtiapine [an antipsychotic medication] .25mg .by mouth at bedtime .
Review of the Physician's Order dated 2/26/2022, revealed .Citalopram [an antidepressant] .by mouth one time day .DEPRESSION .
Review of the MAR for 2/2022 and 3/2022, revealed Resident #29 received both antidepressant and antipsychotic medications daily from 2/25/2022 to 3/30/2022 and there was no monitoring for side effects or adverse reactions.
During an interview on 3/30/2022 at 12:47 PM, the Director of Nursing (DON) stated, .nurses should be monitoring for the side effects .adverse reactions for the use of an antianxiety, antidepressant, psychotropic and antipsychotic medications .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide 5 of 5 sampled residents (Resident #2, #8, #21, #26...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide 5 of 5 sampled residents (Resident #2, #8, #21, #26, and #32) reviewed with the Advanced Beneficiary Notice (ABN), Center for Medicare and Medicaid Services (CMS)-10055 when therapy services were discontinued, and the resident remained in the facility for long-term care services or was discharged from the facility. This failure left the residents without information related to the cost of therapy services if they desired to continue the services in the facility and did not allow for them to have an informed choice.
The findings include:
Review of the facility's policy titled, Policy & [and] Procedure: Advanced Beneficiary Notice, dated 2/1/2017, revealed .To provide a resident or the responsible party/representative with a notice that skilled will be discontinued as it related to financial liability and their specific rights to appeal when the resident no longer meets skilled care requirements .A resident or their responsible party/representative will be notified in a timely manner when the resident no longer meets the requirements for skilled care .the form will be reviewed with the resident or responsible party/ representative .Signatures will be obtained from the resident or their responsible party/representative and dated to acknowledge they have received .
Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Blindness, and Peripheral Vascular Disease.
Review of the ABN for Resident #2 revealed her skilled days ended on 10/1/2021 and the responsible party signed the form on 9/30/2021. The facility failed to provide a timely notice, therefore, the resident and representative were not provided with the choice to continue the services, pay privately for the services, or to stop the services.
Review of the medical record, revealed Resident #8 was admitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Dysphagia, Depression, Anxiety, Schizophrenia, Dementia, Impulse Disorder and Bipolar Disorder.
Review of the ABN for Resident #8 revealed her skilled days ended on 10/15/2021 and the resident signed the form on 10/15/2021. The facility failed to provide a timely notice, therefore, the resident and representative were not provided with the choice to continue the services, pay privately for the services, or to stop the services.
Review of the medical record, revealed Resident #21 was admitted to the facility on [DATE] with diagnoses of Dementia, Bradycardia, Pneumonia, and Malnutrition.
Review of the ABN for Resident #21 revealed his skilled days ended on 1/14/2022 and the responsible party signed the form on 1/14/2022. The facility failed to provide a timely notice, therefore, the resident and representative were not provided with the choice to continue the services, pay privately for the services, or to stop the services.
Review of the medical record, revealed Resident #26 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses of Congestive Heart Failure, Stage 3 Pressure Ulcer Left Heel, Anxiety Disorder, and Muscle Weakness.
Review of the ABN for Resident #26 revealed his skilled days ended on 12/14/2021 and the responsible party signed the form on 12/14/2021. The facility failed to provide a timely notice, therefore, the resident and representative were not provided with the choice to continue the services, pay privately for the services, or to stop the services.
Review of the medical record, revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of Respiratory Failure, Hypokalemia, Pneumonitis, and Diarrhea.
Review of the ABN for Resident #32 revealed her skilled days ended on 12/31/2021 and the resident signed the form on12/31/2021. The facility failed to provide a timely notice, therefore, the resident and representative were not provided with the choice to continue the services, pay privately for the services, or to stop the services.
During an interview on 3/29/2022 at 10:50 AM, the Minimum Data Set (MDS) Coordinator stated, .I don't know the timeframe for the appeal after the end of skilled services .
During an interview on 3/30/2022 9:35 AM, the Director of Nursing (DON) confirmed that a one day notice or less is not acceptable for notification that services are ending.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
Concerns
- • 19 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade D (43/100). Below average facility with significant concerns.
Bottom line: Trust Score of 43/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Towne Square Care Of Puryear's CMS Rating?
CMS assigns TOWNE SQUARE CARE OF PURYEAR an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Tennessee, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Towne Square Care Of Puryear Staffed?
CMS rates TOWNE SQUARE CARE OF PURYEAR's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.
What Have Inspectors Found at Towne Square Care Of Puryear?
State health inspectors documented 19 deficiencies at TOWNE SQUARE CARE OF PURYEAR during 2022 to 2025. These included: 19 with potential for harm.
Who Owns and Operates Towne Square Care Of Puryear?
TOWNE SQUARE CARE OF PURYEAR is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 32 certified beds and approximately 25 residents (about 78% occupancy), it is a smaller facility located in PURYEAR, Tennessee.
How Does Towne Square Care Of Puryear Compare to Other Tennessee Nursing Homes?
Compared to the 100 nursing homes in Tennessee, TOWNE SQUARE CARE OF PURYEAR's overall rating (1 stars) is below the state average of 2.8 and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Towne Square Care Of Puryear?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Towne Square Care Of Puryear Safe?
Based on CMS inspection data, TOWNE SQUARE CARE OF PURYEAR has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Tennessee. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Towne Square Care Of Puryear Stick Around?
TOWNE SQUARE CARE OF PURYEAR has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Towne Square Care Of Puryear Ever Fined?
TOWNE SQUARE CARE OF PURYEAR has been fined $5,244 across 1 penalty action. This is below the Tennessee average of $33,131. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Towne Square Care Of Puryear on Any Federal Watch List?
TOWNE SQUARE CARE OF PURYEAR is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.