Federal inspectors notified the facility's administrator and director of nursing of two immediate jeopardy violations on June 7, 2024, after finding the facility had failed to protect residents from physical, mental and verbal abuse dating back to March 22, 2024. A second immediate jeopardy violation was identified for the same date when a certified nurse aide began a personal relationship with a resident.
The administrator received an allegation of exploitation on July 12, 2023, regarding a personal relationship between CNA 1 and resident R71. The administrator failed to identify this relationship as potential exploitation and did not investigate or report the allegation, according to the inspection report.
Federal regulations require nursing home administrators to interview witnesses, suspend employees pending investigation findings, and provide written reports of abuse investigations to state agencies. The facility's own policy mandates that administrators conduct thorough investigations including interviews with reporting parties, witnesses, residents, and staff members on all shifts.
The facility operates 104 beds and serves residents with conditions ranging from dementia to cerebral palsy.
Beyond the immediate jeopardy violations, inspectors found a pattern of care failures affecting basic resident safety and medical needs.
A resident with cerebral palsy and no upper body core strength was repeatedly found without required body pillows that were ordered by a physician to prevent aspiration. The resident had a gastric feeding tube and needed bilateral body pillows placed under fitted sheets for torso support.
During four separate observations between June 5-6, 2024, inspectors found the resident in bed without the required pillows. CNA 5 told inspectors he was not aware of the physician order for pillows under the fitted sheet. Licensed Practical Nurse 3 said she had never placed pillows under the resident's sheet and was unaware of the order.
When LPN 5 confirmed she knew about the physician order, she could not explain why the pillows were missing or when they were removed.
Respiratory care violations put another resident at risk of infection. Inspectors found a nebulizer medication chamber that still contained medication and had not been rinsed after use. The equipment was not stored in the required plastic storage bag.
The resident, who had chronic obstructive pulmonary disease and scored 14 out of 15 on cognitive testing, told inspectors that staff placed the medication equipment in a basket behind her bed without rinsing it. She said initial instructions indicated the mouthpiece and medication chamber should be boiled for five minutes after each use.
Registered Nurse 1 confirmed the medication chamber contained residual medication and the equipment was not properly bagged. The director of nursing acknowledged that nurses should wash equipment with soap and water, dry it with paper towels, and place items in storage bags after each use.
Four residents used bed rails without required informed consent documentation. Federal regulations mandate that facilities assess residents for safety risks, review risks and benefits with residents or representatives, and obtain informed consent before installing bed rails.
One resident told inspectors, "I hate these damn things, they antagonize me," when asked about his bed rails. When asked if anyone had reviewed risks and benefits, he said, "No risk/benefits - I hate them damn things."
Another cognitively intact resident said no one had discussed risks or benefits of bed rails with him.
One resident fell out of bed and hit her cheek on a side rail. Inspectors observed that bilateral upper quarter rails had been wrapped in pipe insulation padding after the incident. A registered nurse explained the padding was added because "she fell out of bed and hit her cheek on the siderail."
The facility's daily nurse staffing posting failed to include required information for families and visitors. The posting displayed only the number of staff in each category but omitted the facility name, census for each shift, and total hours worked by nursing staff.
Human resources staff told inspectors the posting "may not be every day" and numbers were usually posted "the day after" rather than daily. The facility had no policy regarding nurse staff posting requirements.
Medication storage violations created risks for all 104 residents. In the Blue Hall medication room, inspectors found 20 expired medications and supplements, some dating back to February 2023. Expired items included omeprazole, zinc sulfate, iron supplements, and various vitamins.
A phlebotomy cart contained expired blood collection tubes, including light blue vacutainer tubes that expired December 31, 2023. One medication cart had discontinued oxycodone still available, despite facility policy requiring immediate removal of discontinued narcotics.
The director of nursing acknowledged expired medications should not be available for use and should be removed immediately.
A consultant pharmacist failed to identify irregularities with a resident's lorazepam prescription. The resident had been receiving the anti-anxiety medication as needed since May 9, 2023, without the required 14-day stop date or physician documentation of clinical rationale for continued use.
Monthly medication regimen reviews from May 2023 through May 2024 contained no pharmacist recommendations to address the missing stop date or request physician rationale. The prescribing physician confirmed he had not documented rationale for continued lorazepam use.
Meal service failures affected 50 residents on two halls. Designated meal times were 8:00 a.m. for breakfast, noon for lunch, and 5:00 p.m. for dinner. However, lunch consistently arrived between 1:30 p.m. and 2:19 p.m.
Residents at a council meeting expressed particular concern about late meals affecting their medical conditions. Two diabetic residents worried about receiving insulin before delayed meals. Other residents said late dinners affected their acid reflux.
One resident had not received lunch by 1:39 p.m. and said trays "should be there at noon or 12:30 p.m." Another resident waited until after 2:25 p.m. without receiving his meal.
Certified nurse aides confirmed room trays "always come late" and said they had seen meals served as late as 3:00 p.m. Staff said late meal service made it difficult to complete other resident care duties.
Family members were observed giving a protein shake to their relative, explaining that lunch trays were always served late and "that's too late for lunch."
The dietary manager attributed delays to poor communication between nursing and dietary staff, saying a list of dining room attendees would help serve room trays earlier.
Unit managers for two halls said they were unaware meals were served as late as 2:00 p.m. and agreed such delays were unacceptable and impacted other resident care.
Federal inspectors received a credible allegation of compliance on June 7, 2024, and validated that corrective plans had removed the immediacy of deficient practices by June 8, 2024.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chatuge Regional Nursing Home from 2024-06-08 including all violations, facility responses, and corrective action plans.
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