Waters of Smyrna: Immediate Jeopardy Restraint Violations - TN

Federal inspectors found immediate jeopardy violations at The Waters of Smyrna during a June complaint investigation, discovering that Resident #15 had been confined to the specialized chair since shortly after her December admission. The 73-bed facility's own policy required physician orders and regular monitoring for physical restraints, but staff could produce neither.

The restraint caused injuries twice. On March 10, a nursing assistant found Resident #15 with a 7.5-centimeter bleeding skin tear on her right calf after she tried to get out of the chair. Less than a month later, the Director of Nursing documented finding Resident #15 "anxious/restless" with blood on her leg from rubbing against chair parts "due to restlessness."

"She is unaware due to current cognitive status," the nursing director wrote.

Resident #15 scored a 2 on cognitive testing, indicating severe impairment. She could not remove the tray table herself, yet inspectors observed her throughout June pulling at the restraint with both hands and lifting her body off the seat. Staff never responded.

The chair arrived at the suggestion of administrators, not family request. The MDS Coordinator told inspectors Resident #15 got the chair "a week after she came" because "she was trying to get up and kept falling and hurting herself."

But no physician had ordered it. The facility's Director of Nursing admitted she "could not say that the staff had any training" on the chair and acknowledged "it could be seen as a restraint." When asked if facilities could restrain residents at family request, she answered no.

Multiple staff members described the device as a restraint. "I would consider that tray a restraint," said Licensed Practical Nurse W. "I thought nursing homes quit using those years ago."

The family member who inspectors contacted said he "didn't request that chair" and had never signed consent for a restraint. The facility's Nurse Practitioner confirmed Resident #15 lacked the mental capacity to remove the tray herself.

Yet administrators coded Resident #15 as having no restraints on her quarterly assessment. The MDS Coordinator initially claimed this was because "she didn't have the tray on all the time," but later admitted Resident #15 had used the chair continuously since one week after admission.

The restraint violations coincided with a pattern of sexual abuse that administrators knew about but failed to investigate or report to state authorities.

Resident #10, who had no cognitive impairment, spent over a year touching female residents without permission. Three women reported incidents to staff, but the facility conducted no formal investigations.

Resident #6, who has spastic quadriplegic cerebral palsy and uses a motorized wheelchair, told inspectors that Resident #10 "keeps rubbing my leg" and "reaches towards me to hold my hands." She said the unwanted contact began in June 2023 and continued through the inspection.

"I tell him to stop, but he doesn't and just laughs," she said. "Sometimes I don't want to leave my room because he makes me feel uncomfortable."

Resident #7, who has Parkinson's disease and moderate cognitive impairment, reported similar experiences. "He always reaches to hold my hand. I would slap his hands away," she told inspectors.

The most recent incident occurred June 11, when Resident #10 entered Resident #18's room and "demanded I give him a kiss, then proceeded to come toward me," according to her account. "I yelled for him to get out my room."

When inspectors interviewed Resident #10, he admitted to the behavior. "I was sent out yesterday because I told [Resident #18] to give me a kiss on Tuesday, and she told on me," he said, smirking. Asked about previous incidents, he laughed and acknowledged, "I had a resident report that I was rubbing her hair."

The facility's Activities Director kept detailed logs of Resident #10's behavior during group activities. "He places his hands wherever he can on female residents such as hands, legs, and thighs. Then tells them you know you want it," she told inspectors. "Female residents are afraid of him."

She reported everything to administrators, who told her "as long as he doesn't hurt anyone there's nothing they can do." When she tried implementing assigned seating to protect residents, administrators said she couldn't exclude him from activities.

The facility's ombudsman confirmed that on February 12, Residents #6 and #7 reported the unwanted touching to her after administrators failed to act. "The facility hadn't put anything in place to address the incidents that were reported to them by the residents," the ombudsman said.

Federal regulations require nursing homes to report suspected abuse within two hours and conduct thorough investigations. The facility did neither.

Administrator, who served as the abuse coordinator, admitted the incidents weren't investigated or reported. When asked what constituted sexual abuse, he initially said it would be "when a staff member or resident touched another resident inappropriately," but then minimized resident-to-resident contact, comparing it to holding hands during prayer.

The Director of Nursing acknowledged that "a resident attempting to kiss another resident without permission" would be sexual abuse, yet confirmed the facility never reported the June 11 incident involving Resident #18.

By June 12, administrators finally sent Resident #10 to a hospital for psychiatric evaluation. During that evaluation, he admitted to touching others inappropriately without consent and said he understood he could face assault charges.

The inspection revealed broader staffing problems that affected all residents. The facility operated with a one-star staffing rating and triggered federal warnings for "excessively low weekend staffing" throughout 2023.

On June 11, only three nursing assistants covered 73 residents during breakfast. Meal carts sat in hallways with untouched trays while staff struggled to reach everyone. The dining room remained closed for dinner service due to insufficient staff.

Resident #12 told inspectors he "hardly ever seen a Certified Nursing Assistant" and sometimes waited 45 minutes to an hour for call light responses. "I watch the clock and I have a phone," he explained.

Multiple residents reported similar delays. Resident #20 said her call light stayed on for an hour and a half, with staff promising to return but never coming back. "If they tell me they will be back, I expect them to," she said.

Family members described finding residents in soiled conditions for hours. One daughter said she repeatedly found her mother, who needs extensive assistance with meals, sitting with untouched food on her bedside table.

The facility also improperly administered seizure medication to Resident #15. Nurses gave her Lorazepam 17 times over three months, documenting "agitation" or "anxiety" as reasons, despite physician orders specifying the medication was only for seizure activity.

The hospice nurse overseeing Resident #15's care told inspectors she had "educated the staff that the PRN Lorazepam is for seizures" but the facility continued using it for behavioral management. "Inappropriate use of Lorazepam," she called it.

Nurses admitted they gave the medication when Resident #15 became upset, with one explaining that when "her hands start shaking" from agitation, "that is the seizure activity, and that's when we give it." None contacted physicians about supposed seizure episodes.

Food safety violations affected all residents. Inspectors found expired nutritional supplements, unlabeled condiments, and contaminated ice machines. One nourishment room contained supplements with April delivery dates still being stored in June, while ice machines showed pink debris on interior surfaces.

The immediate jeopardy finding remains ongoing, with federal officials requiring the facility to submit detailed correction plans for the restraint and sexual abuse violations that put residents at continuing risk of harm.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for The Waters of Smyrna, LLC from 2024-06-21 including all violations, facility responses, and corrective action plans.

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