Graystone Manor at Bellmeade

An allegation of resident abuse was not reported to the Area Agency on Aging until several hours after the incident was discovered.

A staff member physically abused a resident by slapping them in the face in response to being bitten.

A resident's assessment was not updated to reflect significant changes in behaviors and care needs following an incident in May 2025.

During a fire drill, residents were evacuated to the building's front entrance rather than to a designated public thoroughfare or fire-safe area.

The medication cart containing resident medications was observed unlocked and unattended on two occasions.

Medication Administration Records lacked documentation for prescribed insulin doses, and several residents did not receive prescribed medications because they were unavailable in the home.

Resident records on a laptop and a binder containing controlled medication information were observed unattended and unsecured on a medication cart.

An antifungal powder treatment was found unlocked, unattended, and accessible in a resident's bathroom without a physician's order.

An insulin pen stored in a medication cart was not labeled with the date and initials of the staff person who opened it.

A resident's glucometer was not calibrated, resulting in incorrect date/time displays and discrepancies between device readings and the MAR.

No carbon monoxide detectors were present near the two gas-fired hot water heaters in the basement.

A direct care staff person lacked a valid high school diploma, GED, or active registry status from an accredited school.

A staff member's training record was missing required documentation for resident rights, emergency plans, and abuse reporting.

An unlocked, unattended medication tube was found accessible in a resident's room despite the resident not being assessed for self-administration.