The dangerous temperatures at Weakley Rehabilitation and Nursing Center created an immediate jeopardy situation that federal inspectors found still ongoing when they arrived June 24. Two residents with severe cognitive impairment lived in rooms where water measured 123 degrees, well above the state's maximum of 115 degrees.
Resident #43, who has Alzheimer's disease and wears a wander guard, told inspectors the water "gets too hot and will scald you if you don't add cold water with the hot water." Her bathroom sink measured 123 degrees when the maintenance director tested it alongside inspectors.
"It's hot. It's over the limit today girls," the maintenance director told inspectors. "We had trouble with that boiler, so I had to turn it up."
The problem started the previous week when birds got into an uncovered exhaust pipe, shutting down the water heater. Staff called the maintenance director reporting they had no hot water. He found the birds, cleared the pipe, and boosted the temperature to 134 degrees to restore hot water quickly.
But he never turned it back down.
"Last Friday I was good, and I needed to turn it back down," the maintenance director told inspectors. "I didn't turn it back down."
The administrator knew nothing about the dangerous temperatures until inspectors arrived. When asked if she was aware of water temperature problems the previous week, she said "No ma'am." Asked if she'd been notified that day about temperatures exceeding 120 degrees, she again said "No ma'am."
The maintenance director confirmed he checks water temperatures weekly but hadn't documented the low temperatures that prompted him to adjust the heater. He also didn't document when he rechecked temperatures later in the week after cranking up the heat.
"No ma'am," he said when asked if he documented the recheck. "No I had one that was right. I only have to have one from each hall."
Multiple residents faced the scalding risk. Resident #52, who scored a 6 on cognitive testing indicating severe impairment, lived in a room with 123-degree water. Resident #55, who uses a wheelchair and needs maximum assistance with daily activities, had 126-degree water in her room.
Even cognitively intact residents complained. Resident #40 told inspectors "water was hot when washing hands in the bathroom." His room measured 123 degrees.
The facility's fall prevention program proved equally ineffective. Resident #11, an 85-year-old woman with Alzheimer's disease, fell 10 times in five months despite a parade of interventions that failed to address her severe cognitive decline.
Her falls followed a predictable pattern. She would attempt to use the bathroom or retrieve clothing while confused and unsteady. Staff tried wheelchair locks, non-slip socks, toileting schedules, bed alarms, and family education about putting away laundry.
Nothing worked.
On May 8, housekeeping found her on the floor after she tried to get a coat from the closet "so they could get out of facility." This time she had fractured her left femur. The injury required hospitalization, but her family declined surgery. She returned to the nursing home with a broken hip and instructions for activities as tolerated.
The fall committee's interventions grew increasingly disconnected from reality. After her ninth fall, they recommended "nursing staff to re-educate resident on safety awareness during transfers" for a woman who scored a 2 on cognitive testing, indicating she could barely communicate.
"Are the reminders to call for assistance and educate the resident with a BIMS of 2 appropriate interventions," the director of nursing later acknowledged to inspectors. "That should be taken out I don't think she could comprehend to use a call light."
The facility's most dangerous resident was Resident #166, a man with vascular dementia whose behaviors escalated from day one. Within hours of admission from a psychiatric hospital, he struck a nurse in the back, wandered naked through hallways, and displayed sexually inappropriate behavior with another resident's walker while that resident watched from bed.
On January 6, certified nursing assistant E found him in Resident #52's room with his briefs down to his knees, engaged in sexual behavior with the walker. When she tried to redirect him, he grabbed her arm and threatened to break it, then grabbed her throat and said he was going to kill her.
"I just dropped everything and walked out," CNA E told inspectors. No one interviewed her about the incident.
The behaviors continued for two weeks. Resident #166 overturned furniture, urinated on floors, climbed into another resident's bed, and put his hands on residents' heads. Staff prescribed multiple psychiatric medications that proved ineffective.
On January 17, he entered Resident #42's room, took the resident's phone, and when told to put it back, struck Resident #42 in the head with a water glass. The blow caused two lacerations to the forehead. Only then was Resident #166 discharged back to the psychiatric hospital.
"In hindsight, probably not," the director of nursing admitted when asked if adequate interventions had been in place to keep staff and residents safe.
The facility's medication management proved equally problematic. During inspection, nurses left medication carts unlocked and unattended multiple times. On June 24, inspectors watched a nurse unlock a cart, walk away to get a computer mouse, return and walk away again to answer the phone, then enter a resident's room while leaving the cart unlocked in the hallway.
Licensed practical nurse C failed to properly track controlled substances, with actual pill counts not matching the inventory records for anxiety medications. When inspectors discovered the discrepancies, she started to alter the documentation before being told to stop.
The facility's emergency preparedness also fell short. The three-day disaster menu listed peanut butter and protein bars as emergency foods, but neither item was actually stocked in the emergency supply. The dietary supervisor confirmed that menu items should match available supplies.
During wound care, staff violated infection control protocols. A nurse performing dressing changes dropped sterile calcium alginate onto a contaminated surface, then used the contaminated material to dress a pressure wound. She also failed to wear the required gown during the procedure.
The administrator hadn't notified the medical director about the immediate jeopardy water temperatures or convened any emergency quality meetings to address the safety failures. The maintenance director had installed mesh over the exhaust pipe after the bird incident but only after the problem had already caused dangerous conditions for residents.
Resident #11 now requires assistance for all mobility after her hip fracture. The maintenance director finally turned the water heater back down to 120 degrees, but only after inspectors found the dangerous temperatures. The facility's most vulnerable residents had spent days exposed to water hot enough to cause severe burns within seconds of contact.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Weakley Rehabilitation and Nursing Center from 2024-06-29 including all violations, facility responses, and corrective action plans.
Additional Resources
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