Ahc Crestview
Inspection history, citations, penalties and survey trends for this long-term care facility in Brownsville, Tennessee.
- Location
- 704 Dupree Road, Brownsville, Tennessee 38012
- CMS Provider Number
- 445442
- Inspections on file
- 21
- Latest survey
- May 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ahc Crestview during CMS and state inspections, most recent first.
Dangerously high hot water temperatures were found in multiple resident rooms, including those shared by several cognitively impaired individuals who required assistance with ADLs. Facility policy required water temperatures to be kept below a certain threshold, but maintenance staff did not consistently monitor or document water temperatures, leading to unsafe conditions. Staff confirmed the presence of excessively hot water during care activities, and maintenance records were incomplete.
A resident with severe mental illness and cognitive impairment was prescribed a new antipsychotic medication, but the facility did not resubmit the required PASRR screening following this change. Review of records and staff interviews confirmed that the necessary PASRR update was not completed as mandated by policy and federal requirements.
A resident with epilepsy, diabetes, and lower leg contractures, who was cognitively intact but required substantial assistance with bathing, did not receive any scheduled showers over a three-month period despite a care plan specifying showers three times weekly. Documentation and interviews confirmed the lack of provided showers, and the DON acknowledged that the resident should have received this care as planned.
Staff failed to secure and properly store medications, leaving creams and pills unattended in three resident rooms and allowing expired medications to remain in a medication storage area. LPNs and the DON confirmed that medications should not be left at the bedside or in storage past expiration.
Two residents with severe cognitive impairment and psychiatric diagnoses received duplicate doses of antipsychotic medications due to concurrent orders for both brand and generic forms. Medication Administration Records showed both medications were administered at the same time over several months, and the issue persisted despite identification by pharmacy review and notification of nursing leadership.
Two residents received care that did not follow infection control protocols when an LPN failed to disinfect a multi-use insulin vial and perform hand hygiene after glove removal, and another LPN did not clean a stethoscope after verifying gastrostomy tube placement. The DON confirmed these lapses in required infection prevention practices.
A facility failed to implement effective fall interventions and complete neuro checks for residents with severe cognitive impairment. One resident with a BIMS score of 2 and a history of wandering behavior sustained a fall resulting in a right femur fracture. The care plan included reminders for assistive devices and redirection, but these measures were ineffective in preventing the resident's wandering and subsequent fall. The facility did not modify interventions or implement additional measures to address the resident's behaviors, leading to actual harm.
The facility failed to follow proper infection control practices during IV medication administration and hand hygiene during dining. An LPN did not clean an administration port before administering IV medications, and multiple staff members did not perform hand hygiene before and after resident contact and while handling food.
The facility failed to report allegations of abuse involving two residents, despite having a policy that mandates immediate reporting. The Administrator did not report the incident to the state agency within the required timeframe, deeming the altercation as minor.
The facility failed to thoroughly investigate allegations of abuse involving two residents, one with intact cognition and one with severe cognitive impairment. The incident was documented, but the investigation was incomplete, and the results were not reported to the State Agency within the required timeframe.
The facility failed to ensure a care plan meeting and interventions for two cognitively intact residents expressing sexual desires towards one another. Despite multiple incidents of inappropriate sexual behavior in public areas, there was no documentation of a care plan meeting by the IDT to address these behaviors and ensure privacy for the residents.
A resident with severe cognitive impairment and multiple diagnoses had their oxygen concentrator set at 4 liters per minute instead of the prescribed 2 liters per minute. An LPN confirmed the error and adjusted the setting, and the DON confirmed that staff should follow physician's orders.
A registered nurse left a medication cart unlocked and unattended, violating the facility's policy on medication storage. The DON confirmed that the cart should not be left unlocked and out of sight.
Failure to Maintain Safe Water Temperatures in Resident Areas
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards by allowing dangerously elevated hot water temperatures in resident rooms. On 4/28/2025, water temperatures ranging from 128°F to 135°F were measured in six resident rooms, some of which had shared bathrooms. Facility policy required water temperatures to be kept at or below 115°F, and maintenance staff were responsible for regular checks and documentation, which was not consistently performed. Several residents affected by this deficiency were severely cognitively impaired, as indicated by low BIMS scores, and required varying levels of assistance with activities of daily living (ADLs). These residents included individuals with diagnoses such as psychosis, dementia, Parkinson's disease, and other conditions that increased their vulnerability. Observations confirmed that the hot water was present in shared bathrooms used by these residents, and staff interviews corroborated that excessively hot water was noticed during routine care activities. The Maintenance Director was unable to provide documentation of water temperature checks for a specified period, and the boiler serving the affected areas was found to be set above the recommended temperature. The facility's own policy and job descriptions outlined the need for regular monitoring and maintenance to prevent such hazards, but these procedures were not followed, resulting in the exposure of residents to unsafe water temperatures.
Failure to Resubmit PASRR After New Antipsychotic Medication Initiation
Penalty
Summary
The facility failed to resubmit a Preadmission Screening and Resident Review (PASRR) after a resident with a history of serious mental illness was prescribed a new antipsychotic medication. According to facility policy and federal requirements, any change in a resident's symptoms, diagnosis, or medication related to serious mental illness necessitates a new PASRR Level 1 screening. The medical record showed that the resident, who had diagnoses including Bipolar Disorder, Schizophrenia, and Anxiety Disorder, was started on Haloperidol for severe depressive symptoms with psychotic features. Despite this significant medication change, there was no documentation of a new PASRR submission following the addition of Haloperidol. The resident had a history of severe cognitive impairment, as indicated by low BIMS scores, and was receiving multiple psychotropic medications. The last PASRR on file was dated several years prior to the medication change. During an interview, the Admissions Coordinator confirmed awareness of the requirement to resubmit PASRRs upon such changes and acknowledged that a new PASRR had not been completed for this resident since the last one on record. This lapse was identified through policy review, medical record review, and staff interview.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to provide assistance with activities of daily living (ADLs), specifically showering, for a resident who was unable to perform this task independently. According to facility policy, residents who cannot carry out ADLs independently are to receive necessary services, including hygiene and bathing, in accordance with their care plan. The resident in question was admitted with diagnoses of epilepsy, diabetes, and contractures of both lower legs, and was assessed as cognitively intact but requiring substantial to maximum assistance with showers or baths. The care plan specified that the resident preferred and was to receive showers three times a week at bedtime, with sponge baths as an alternative if desired. Medical record review showed that the resident did not receive any showers during the months of February, March, or April, as documented on bathing sheets. During interviews, the resident reported having received only one shower in three years of residency, expressing feelings of being deprioritized for care. Staff interviews confirmed the established shower schedule for the resident's hall, and the DON acknowledged that residents care planned for showers three times a week should be receiving them as specified. These findings indicate a failure to provide the required ADL assistance as outlined in the resident's care plan and facility policy.
Failure to Secure and Properly Store Medications, Including Expired Drugs
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were properly stored and secured, as required by facility policy and professional standards. During observations, medications were found unsecured and unattended in three resident rooms. In one instance, a medication cup containing hydrocortisone and betamethasone creams was left at the bedside of a cognitively intact resident, with a tongue depressor in the cup. In another case, a cognitively intact resident had a medication cup with several pills left in the room, which the resident picked up while preparing to go to dialysis. In a third instance, a tube of wound dressing cream was found on the bed of a resident who did not have an order for any wound cream. Staff interviews confirmed that these medications should not have been left unattended or unsecured in resident rooms. Additionally, expired medications were found in one of the medication storage rooms. Specifically, promethegan suppositories with an expiration date several months prior were discovered in the South 2 Medication Storage Room. Staff interviews, including with the DON and an RN, confirmed that expired medications should not be present in medication storage areas. These findings demonstrate a failure to adhere to medication storage and security protocols as outlined in facility policy.
Failure to Prevent Duplicate Antipsychotic Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation and administration of antipsychotic medications for two residents with severe cognitive impairment and multiple psychiatric diagnoses. For one resident with psychosis, depression, anxiety, and atrial fibrillation, medical records showed duplicate orders for Risperidone and Risperdal, resulting in the resident receiving both medications at the same dosage and time over several months. This duplication was reflected in the Medication Administration Records (MAR) from January through mid-April, with both the brand and generic forms administered concurrently each evening. Similarly, another resident with dementia, PTSD, anxiety, depression, and psychotic disorder had duplicate orders for Quetiapine and Seroquel, leading to both being administered at the same dosage and time over multiple months. The MARs indicated this duplication persisted from late February through mid-April, despite a pharmacist's report identifying the duplicate orders and requesting discontinuation of one. The Director of Nursing confirmed the presence of these duplicate orders and that the nurse practitioner had been notified.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
The facility failed to adhere to infection prevention and control practices during medication administration for two residents. In one instance, an LPN withdrew insulin from a multi-use vial without disinfecting the vial top as required by facility policy, administered the injection, removed gloves, and did not perform hand hygiene afterward. The resident involved had diabetes and was unable to be assessed for mental status due to communication limitations. Facility policy mandates cleaning the vial with an alcohol wipe and performing hand hygiene immediately after glove removal, but these steps were not followed. In another instance, an LPN administered medications via a gastrostomy tube to a resident and used a stethoscope to verify tube placement. After completing the procedure, the LPN exited the room and signed out medications without cleaning the stethoscope, contrary to facility policy requiring reusable equipment to be cleaned and disinfected between residents. The resident had a gastrostomy and was also unable to be assessed for mental status. The DON confirmed during interview that the required infection control practices were not followed in both cases.
Fall Prevention and Neuro Check Deficiencies Identified
Penalty
Summary
The facility failed to ensure effective fall interventions were in place to prevent injury, and failed to complete neuro checks for two out of three sampled residents reviewed for accidents. In the case of Resident #23, who had severe cognitive impairment with a BIMS score of 2, the facility did not implement appropriate interventions despite the resident's history of wandering behavior and attempts to enter other residents' rooms. This lack of effective interventions led to Resident #23 sustaining a fall with a right femur fracture, resulting in actual harm. The facility's failure to follow its policy on fall prevention, including educating residents with a BIMS score of 13 or greater on the use of call lights and modifying interventions as necessary, contributed to the deficiency. Additionally, the facility's care plan for Resident #23 included reminders to use ambulation and transfer assist devices, call for assistance before moving, and redirection for wandering behavior. However, these interventions proved ineffective as Resident #23 continued to exhibit wandering behavior, entering other residents' rooms and attempting to take food and drink items. Despite Resident #23's severe cognitive impairment and documented behaviors, the facility did not adequately modify interventions or implement additional measures to prevent further incidents. The lack of appropriate actions to address Resident #23's behaviors ultimately led to the fall and subsequent fracture.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices during IV medication administration and hand hygiene during dining. Specifically, an LPN did not clean an administration port before administering IV medications and fluids to a resident with a PICC line, which was confirmed by the Director of Nursing. Additionally, multiple staff members, including CNAs and the Life Enrichment Coordinator, did not perform hand hygiene before and after resident contact and while handling food during dining observations. The deficiencies were observed in several instances, such as an LPN laying the PICC tubing on the bed and administering a Heparin flush without cleaning the port, and CNAs handling food and repositioning residents without performing hand hygiene. These actions were confirmed by the Director of Nursing, who acknowledged that proper hand hygiene and cleaning protocols were not followed, increasing the risk of infection spread among residents.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse for two residents, despite having a policy that mandates immediate reporting of such incidents. Resident #68, who had intact cognition, and Resident #185, who had severe cognitive impairment, were involved in a physical altercation where Resident #185 struck Resident #68. The incident was documented in a nurse's note, and the Director of Nursing (DON) was notified. However, the Administrator did not report the incident to the state agency within the required timeframe, as mandated by the facility's abuse prohibition policy. During interviews, it was revealed that the incident was not reported to the state because the Administrator deemed the altercation as minor. The Administrator admitted to not following the policy that requires reporting all allegations of abuse to the state within two hours and completing an investigation within five days. This failure to report the incident to the state agency constitutes a deficiency in adhering to federal and state regulations regarding abuse reporting in long-term care facilities.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents. Resident #68, who has intact cognition, was involved in a physical altercation with Resident #185, who has severe cognitive impairment. The incident occurred in the 200 hallway where Resident #68 struck Resident #185 in the back of the head. Although the incident was documented, the facility did not follow its policy to conduct a thorough investigation, including interviewing all relevant parties and documenting witness statements. The Director of Nursing (DON) was notified, but the investigation was incomplete, and the results were not reported to the State Agency within the required timeframe. During interviews, staff members, including an LPN and the Administrator, acknowledged the incident but did not ensure a comprehensive investigation was conducted. The Administrator admitted that the incident should have been investigated but downplayed its severity. The facility's failure to complete a thorough investigation for the allegations of abuse led to a deficiency in adhering to their Abuse Prohibition Plan and state reporting requirements.
Failure to Ensure Privacy and Intimacy for Cognitively Intact Residents
Penalty
Summary
The facility failed to ensure a care plan meeting was scheduled and interventions implemented for two cognitively intact residents expressing sexual desires towards one another. The facility's policy on Sexual Expression of the Resident, revised on 10/24/2022, mandates that residents with decisional capacity have the right to privacy, including private space for sexual expression. However, the interdisciplinary team (IDT) did not conduct a care plan meeting to ensure the residents' right to privacy and intimacy was respected and documented in their care plans. Resident #31, admitted with diagnoses including Hemiplegia, Anxiety, Depression, Cognitive Communication Deficit, and Schizophrenia, had a BIMS score indicating cognitive intactness. Despite multiple incidents of inappropriate sexual behavior in public areas, including the courtyard and front lobby, there was no documentation of a care plan meeting by the IDT to address these behaviors and ensure privacy for the resident. The resident's care plan and clinical notes repeatedly highlighted inappropriate sexual behaviors and the need for privacy, but no formal care plan meeting was conducted. Similarly, Resident #61, admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Respiratory with Hypoxia, and Depression, also had a BIMS score indicating cognitive intactness. The resident was involved in inappropriate sexual behavior with Resident #31 in public areas. Despite being informed about appropriate and inappropriate locations for such behavior, there was no documentation of a care plan meeting by the IDT to ensure the resident's right to privacy and intimacy. The facility's failure to conduct these care plan meetings resulted in a deficiency in respecting the residents' rights to privacy and intimacy.
Failure to Follow Prescribed Oxygen Administration Orders
Penalty
Summary
The facility failed to follow the prescribed physician orders for oxygen administration for a resident with severe cognitive impairment and multiple diagnoses, including Chronic Obstructive Pulmonary Disease and Hemiplegia. The physician's order specified that oxygen should be administered at 2 liters per minute via nasal cannula as needed for dyspnea or when oxygen saturation levels fell below 88%. However, observations on multiple occasions revealed that the resident's oxygen concentrator was set at 4 liters per minute, which is double the prescribed rate. During an interview, an LPN confirmed that the correct oxygen level according to the physician's order was 2 liters per minute and subsequently adjusted the concentrator to the correct setting. The Director of Nursing also confirmed that staff should follow physician's orders. This discrepancy in oxygen administration was observed over several days, indicating a failure to adhere to the prescribed medical regimen for the resident's respiratory care.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored appropriately when a registered nurse (RN A) left a medication cart unlocked, unattended, and out of line of sight. The facility's policy, revised on 9/5/2023, mandates that all medications be stored in locked compartments and only accessible to authorized personnel. However, during an observation on 4/26/2024, the surveyor found the medication cart in the 400 hallway next to the Nurse's office unlocked. RN A initially stood with the surveyor to observe the cart's contents but subsequently walked away into the Nurse's office, leaving the cart unattended and out of view. During an interview on the same day, the Director of Nursing (DON) confirmed that the medication cart should not be left unlocked and unattended if it is not in the line of sight. This incident highlights a failure in adhering to the facility's medication storage policy, thereby compromising the security and proper handling of medications.
Latest citations in Tennessee
Surveyors found that staff did not follow the facility’s infection prevention policies, including Enhanced Barrier Precautions (EBP), hand hygiene, and urinary catheter management. A respiratory therapist performed trach care and suctioning for two residents with tracheostomies without donning required gowns or masks, placed supplies and an inner cannula on the resident’s abdomen and linens, and left a room wearing contaminated gloves. An RN administered meds via a feeding tube for a resident with a gastrostomy, then performed eyelid scrubs without changing gloves or performing hand hygiene between routes of care and without using a gown despite EBP signage. CNAs delivered and set up lunch trays for three residents who required at least some assistance with hygiene or meals but did not offer hand hygiene before eating, contrary to policy. In addition, a resident with a urinary catheter was observed in bed with the drainage bag lying on the floor, rather than suspended from the bed as confirmed by nursing staff and the IP.
Administration allowed an unqualified individual to be hired and work as an LPN by failing to verify licensure and reconcile name discrepancies across hiring documents. The individual’s I-9, birth certificate, and out-of-state driver’s license reflected one last name, while the TN LPN license verification on file belonged to a different nurse with the same first name but a different last name. Abuse registry checks were completed under both names, but no national background check or documentation explaining the differing names was present. The person was offered a temporary/contract LPN position, worked multiple shifts, and had conflicting separation notices, with no documentation of a formal rehire. The HR Director confirmed there was no hiring policy and that the individual worked onsite as an LPN before being terminated for failure to attend or complete training.
Administration failed to ensure nursing services were provided by qualified personnel when an unlicensed individual was hired and allowed to work as an RN and Unit Manager using another nurse’s license. Pre-employment documents for this staff member contained inconsistent SSNs and birth dates across the application, background check, W-4, and I-9, and the background report noted the SSN could not be validated. No abuse registry check or RN license verification was completed before hire, and a later license verification showed the last name on the RN license did not match the individual’s last name. The imposter, a walk-in applicant without a resume, worked multiple shifts providing nursing services before being separated as a voluntary termination, and facility staff did not question the documented discrepancies.
Administration allowed an unlicensed individual to be hired twice and function as an LPN using another LPN’s Tennessee license. During the first hire, conflicting SSNs appeared on the application and tax forms, the I‑9 identified the imposter by her own name and out‑of‑state driver’s license, and the license verification was for a different nurse with only the same first name; no Tennessee Abuse Registry check was documented, and the imposter worked multiple shifts before resigning. During the second hire, a different SSN was used, no I‑9 or supporting identity documents were on file, and the same other nurse’s license was again used for verification; the imposter worked several days before resigning. The Administrator reported that the same resume was used for both hires and that the facility had no formal hiring policy, only a checklist.
Administration failed to ensure nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s license. The facility’s own employment policy requiring HR completion of I-9 Section 2, consistent SSN use, and verification of license and abuse registry status was not followed. The imposter’s application and background check contained conflicting SSNs, names, and birthdates, and the I-9 was not signed by HR. An abuse registry check was run only on one SSN, and discrepancies were not investigated. Time records showed the imposter worked several shifts and had patient access, while leadership later confirmed she remained on the books until being treated as a voluntary termination for not picking up shifts.
Administration failed to ensure nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN under another nurse’s license. Facility records showed multiple unexplained discrepancies in the individual’s name, SSN, and birthdate across the background check, I-9, W-4, Consumer Information Sheet, and separation notice, and the I-9 was never completed or signed by facility staff. Time records confirmed the imposter worked several shifts as an RN before being terminated for no call/no show, and an abuse registry check was not completed until long after termination. The facility did not produce hiring policies or documentation that anyone questioned the conflicting identification information before or during this person’s employment.
Staff failed to honor a resident’s right to refuse care when CNAs proceeded with a scheduled shower despite the resident verbally declining. The resident, who had severe dementia with agitation and was dependent on staff for bathing, had a care plan directing staff to discuss objections, inform of risks, offer choices, and accept refusals. Instead, after the resident said they did not want a shower, one CNA pulled off the covers, and the CNAs placed the resident in a shower chair and continued with the shower because it was the resident’s assigned shower day, contrary to facility policy and the care plan.
A resident with severe cognitive impairment and multiple comorbidities was admitted for rehab and had clearly documented full code status in the face sheet, care plan, and physician orders. During the night, the resident was last observed awake and later found unresponsive with no heart sounds, pulse, or respirations. Staff initiated CPR and continued until the resident was pronounced deceased, but the record contained no evidence that EMS/911 was contacted or that an AED was obtained or used, despite facility policy and leadership expectations that full code residents receive CPR with 911 activation and AED use, and despite the presence of two AEDs in the facility.
A resident with severe cognitive impairment, type 2 DM, CKD, and a history of falls had physician orders for blood glucose checks before meals and at bedtime and for sliding scale insulin aspart four times daily. Facility policy required verification of insulin orders, blood glucose monitoring per orders, and documentation of results and doses. However, after an NP attempted to edit the sliding scale order in the EHR, the order remained unsigned and inactive in the queue, preventing it from appearing on the MAR. Nursing staff did not identify that the insulin order was missing, resulting in multiple missed blood glucose checks and insulin doses over several days, despite the resident’s care plan directing staff to follow physician orders for diabetes management.
The facility failed to maintain a clean and sanitary environment in multiple resident rooms and bathrooms, despite policies requiring routine cleaning and disinfection. Observations over several days found a motorized wheelchair and another wheelchair with attached cushion soiled with dried, multi-colored debris. Several resident bathrooms had unclean conditions, including a trash can without a liner and with dried brown residue, toilets with dried yellow residue on the seats, and yellow/orange or brown substances around the bases of multiple toilets. During an on-site check, the Administrator confirmed that the residue around one toilet could be wiped away and that the area was not clean.
Failure to Follow EBP, Hand Hygiene, and Catheter Practices During Respiratory, Enteral, and Daily Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies, including Enhanced Barrier Precautions (EBP), hand hygiene, and urinary catheter management. The facility’s EBP policy required staff to perform hand hygiene, review EBP signage, and don gown and gloves prior to high-contact resident care activities such as tracheostomy care, suctioning, and device care, then remove PPE and perform hand hygiene before leaving the resident’s room. For Resident #1, who had epilepsy, acute on chronic respiratory failure, a tracheostomy, and ventilator dependence, a respiratory therapist entered the room where EBP signage was posted, used pocket hand sanitizer, and donned gloves but did not don a gown or mask. The therapist placed clean gauze and used split gauze directly on the resident’s abdomen, allowed the tracheostomy inner cannula to roll from the abdomen onto the linens, and then left the room carrying a box while still wearing the same contaminated gloves, only discarding them later at the respiratory therapy cart. The therapist acknowledged not setting up supplies appropriately, not discarding gloves and performing hand hygiene before leaving the room, and not following EBP, stating she believed EBP was only required for residents with an active infection. For Resident #8, who had traumatic brain injury, quadriplegia, acute respiratory failure, and a tracheostomy, the same respiratory therapist again entered a room with EBP signage and donned gloves but no gown or mask before performing tracheal suctioning using an in-line suction catheter. The resident had reflex coughing during suctioning. After completing suctioning, the therapist discarded gloves and used pocket hand sanitizer but again did not follow the full EBP requirements. The infection preventionist later confirmed that EBP was required for high-contact care such as tracheal care and suctioning, and that gloves should be discarded before leaving the room with hand hygiene performed each time gloves are removed. The facility also failed to follow EBP and hand hygiene practices during medication administration for Resident #22, who had chronic respiratory failure, quadriplegia, tracheostomy status, and gastrostomy status, and who had long- and short-term memory deficits with severely impaired decision-making. A registered nurse entered the resident’s room, where EBP signage was posted, donned gloves but not a gown, and administered medications via the gastrostomy tube using a piston syringe, flushing with water as ordered. With the same used gloves still on, the nurse rinsed the piston syringe in the room sink, set it on paper towels to dry, and then performed OcuSoft eyelid scrubs to both eyes without changing gloves or performing hand hygiene between the different routes of care. The nurse confirmed she did not don a gown and did not perform hand hygiene or change gloves between the feeding tube medication administration and the eye care, and the infection preventionist confirmed that EBP and hand hygiene with glove changes were expected between administering medications by different routes. Additional deficiencies were identified in hand hygiene assistance before meals and urinary catheter management. The facility’s resident handwashing policy required staff to offer hand hygiene before meals. Resident #47, who had acute and chronic respiratory failure, epilepsy, atrial fibrillation, and chronic pulmonary edema and was dependent for hygiene and feeding assistance, received a lunch tray from a CNA who set up the tray and left without offering hand hygiene assistance. Resident #31, with COPD, acute and chronic respiratory failure, morbid obesity, and a care plan indicating partial to moderate assistance with hygiene, also had a lunch tray delivered and set up by a CNA who exited without offering hand hygiene. Resident #66, with COPD, chronic respiratory failure, generalized muscle weakness, and substantial to maximal ADL needs including meal assistance, likewise had a lunch tray delivered and set up without being offered hand hygiene. One CNA acknowledged residents were to be offered hand hygiene before meals, and another stated she had not offered hand hygiene unless residents mentioned it. The infection preventionist confirmed staff were expected to offer hand hygiene assistance to all residents prior to meals. The facility further failed to maintain proper urinary catheter bag positioning for Resident #15, who had chronic osteomyelitis, depression, anxiety, paraplegia, and required assistance with ADLs, including urinary catheter care per orders and protocol. During observation, the resident was in bed with the urinary catheter drainage bag lying on the floor beside the bed. A licensed practical nurse confirmed the catheter bag should be hung from the bed, and the infection preventionist confirmed catheter bags were to be suspended off the ground to prevent infection. These observations demonstrated non-adherence to the facility’s infection prevention and control practices related to EBP, hand hygiene, and catheter management across multiple residents and care situations.
Imposter Hired and Employed as LPN Without Proper License Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an LPN using another nurse’s Tennessee license. Personnel file review showed that the individual, referred to as Imposter Nurse A, had an I-9 form completed with her legal first and last name, supported by a birth certificate and an out-of-state driver’s license, and a Tennessee Criminal History Record Request indicating no Tennessee criminal history under that name. However, the nursing license verification in the file was for a different person, an LPN with the same first name but a different last name (LPN C). Two Tennessee Abuse Registry checks were present, one under LPN C’s name and one under Imposter Nurse A’s name, but there was no documentation explaining or reconciling the name discrepancies between the I-9, the license verification, and other employment documents. There was also no national background check in the personnel file. The facility issued an offer letter to Imposter Nurse A for a temporary/contract LPN position, and time sheets showed she worked multiple shifts on several dates. Two separation notices documented voluntary separation without notice, with differing last days worked, and there was no paperwork provided to explain her apparent rehire after the first termination. During interview, the Human Resource Director acknowledged there was no hiring policy, confirmed that Imposter Nurse A worked onsite as an LPN, and stated she was terminated for failure to attend or complete training and for failure to come in as needed. No information was provided to surveyors showing any cross-check or investigation of the inconsistent names across the employment application, I-9 form, and nursing license verification, resulting in the facility employing an unqualified person in an LPN role.
Imposter RN Hired and Allowed to Function Without Proper Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s Tennessee license. Facility policy titled “Abuse Program Policy” required pre-employment screening, including obtaining a copy of the state license for licensed positions and completing a criminal background check per state statute. The application for employment for the imposter nurse contained a scratched-out Social Security Number (SSN) with a different SSN written above that did not match the SSN on the I-9 form, and the birth date on the application also did not match the I-9. The background screening report showed an SSN and birth date that did not match the I-9 and included a note stating “UNABLE TO VALIDATE SSN.” A W-4 form contained an SSN that did not match the background check. The I-9 form listed the imposter’s legal first and last name, with a Social Security card and valid Tennessee driver’s license, but the birth date on the I-9 differed from the birth date on the background check. Review of the personnel file revealed no evidence that an abuse registry check was completed prior to hire, and there was no evidence that a license verification was done before the imposter nurse’s start date. Time cards showed the imposter worked multiple days in February and March as a Unit Manager. A later QuickConfirm license verification showed that the last name on the validated RN license did not match the imposter’s last name. Interviews with the DON, HR representative, and Administrator confirmed that the imposter was a walk-in applicant who did not provide a resume, that in-house HR was responsible for ordering background checks with corporate as backup, and that the imposter worked in the facility as a Unit Manager and was only separated as a voluntary termination for inability to uphold weekend schedule obligations. There was no evidence that the facility questioned the discrepancies in names, birth dates, or SSNs on the pre-employment documents, resulting in the employment of an unqualified person to render nursing services as an RN.
Imposter Nurse Hired Twice and Allowed to Function as LPN Without Proper Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and allowed to function as an LPN on two separate occasions using another nurse’s Tennessee license. For the first hire, the personnel file showed an employment application dated 02/08/2023 with a Social Security Number (SSN) that did not match the SSN on the W‑4 form dated 02/13/2023. The I‑9 form dated 02/13/2023 listed the imposter’s legal first and last name, supported by a birth certificate and an out‑of‑state driver’s license, and the last name on the I‑9 matched the driver’s license. However, the license verification form in the file was for a different individual, an LPN with the same first name but a different last name, and there was no evidence that a Tennessee Abuse Registry check was completed prior to the 02/13/2023 hire date. Time punch records showed the imposter worked multiple shifts in February, March, April, and May 2023 before being terminated on 06/06/2023, with the termination form citing voluntary resignation due to chronic absenteeism and tardiness. For the second hire, the imposter was rehired with a personnel file showing that the SSN on the employment application, W‑4, and background check matched each other but differed from the two SSNs used during the first hire, meaning three different SSNs were used across the two employment periods. There was no I‑9 form or supporting identity documents in the file for the rehire. A license verification form again showed a nursing license in the name of the same LPN whose license had been used previously, with the same first name as the imposter but a different last name and a later expiration date. The background screening report dated 02/13/2024 used the SSN from the employee application, which did not match the SSN previously submitted on the I‑9 form from the first hire. Time punch data showed the imposter worked several days in May 2024 before a termination dated 06/24/2024, which documented voluntary resignation after failing to provide a schedule and not returning after orientation. In an interview, the Administrator stated the facility used the same resume for both hires and that the facility did not have a hiring policy, only a checklist.
Imposter RN Hired and Allowed to Work Without Proper License Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s Tennessee RN license. The facility’s Employment policy required the HR Director to complete Section 2 of the I-9, conduct background investigations, and verify licenses and abuse registry status using the applicant’s registration or Social Security number. Review of the imposter’s employment application showed a Social Security number scratched out and replaced with another number that did not match the SSN used on the background check. The background check listed both the imposter’s name and the legitimate RN’s name, and it showed the legitimate RN’s license number. The birthdate on the I-9 did not match the birthdate on the background check, and Section 2 of the I-9 was not signed by the HR Director as required by policy. Further review showed that an abuse registry search was completed using the SSN from the Social Security card submitted with the I-9, but no search was conducted using the SSN listed on the background check. The separation notice for the imposter listed her real first and last name with an SSN that again did not match the SSN on the background check, and documented employment from mid-June to late November with the reason for termination as voluntary due to not picking up shifts for over three months. Employee time entries showed the imposter worked multiple days in June and one day in July. The DON confirmed that the imposter used an online artificial intelligence website for charting and stated the imposter had access to patients for one day in July. The Administrator confirmed the imposter was considered employed during the stated period and was not formally fired or documented as having quit. There was no evidence that the facility questioned the discrepancies in names, birthdates, or Social Security numbers on the pre-employment documents, resulting in the employment of an unqualified person as an RN.
Imposter RN Hired and Allowed to Work Despite Multiple Identification Discrepancies
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s Tennessee license. Personnel file and document review showed multiple inconsistencies in the imposter nurse’s identifying information that were not questioned by the facility. The background check dated 06/14/2024 used a Social Security Number (SSN) that did not match the SSN on the Social Security card submitted. The I-9 form dated 06/15/2024 listed the imposter’s legal first and last name, with a copy of her Social Security card and a valid Tennessee driver’s license, but the SSN on the I-9 did not match the SSN on the Social Security card. The I-9 form was not completed, signed, or dated by any facility representative. Time punch data showed the imposter nurse worked multiple days in June and July 2024. A separation notice dated 07/31/2024 listed the imposter’s real first and last name with an SSN that did not match the SSN on the I-9 form, and documented employment dates from 06/12/2024 to 07/31/2024 with termination for no call/no show. An undated Consumer Information Sheet listed the imposter’s first and last name with the legitimate RN’s last name as her middle name, a birth year that did not match the I-9, and an SSN that did not match the SSN on the W-4 form or the separation notice. The abuse registry check for the imposter was not completed until 08/04/2025, after termination. The facility did not provide any hiring policies and there was no evidence that staff questioned the discrepancies in names, birth dates, or SSNs on the pre-employment forms, resulting in the employment of an unqualified person as an RN.
Failure to Honor Resident’s Refusal of Shower and Right to Self-Determination
Penalty
Summary
The deficiency involves staff failure to honor a resident’s right to self-determination and refusal of treatment, specifically related to bathing. Facility policy on Resident Rights and Responsibilities states that residents have the right to refuse treatment and to be informed of the medical consequences of such refusal, and to exercise their rights without discrimination or reprisal. Resident #31, admitted in late 2023, had severe dementia with agitation, a BIMS score of 3 indicating severe cognitive impairment, and was dependent on staff for showering and personal hygiene. The resident’s care plan identified behavior problems and resistance to care related to dementia, knowledge deficit, denial of illness and risk factors, and mental/emotional illness, with interventions directing staff to discuss objections and fears, inform the resident of risks of non-compliance, offer choices, and accept and respect the resident’s right to refuse care. Despite these policies and care plan interventions, staff proceeded with a shower after the resident refused. A CNA assigned to the resident reported that the resident had refused a shower, and another CNA responded that it was the resident’s shower day and that the shower should be provided. According to written statements, when the CNAs entered the room and informed the resident it was shower day, the resident stated, “No I don’t want a shower.” One CNA then told the resident they were getting a shower and pulled the covers off the resident. The CNAs placed the resident in a shower chair and continued with the shower despite the expressed refusal. During a later interview, the CNA confirmed instructing the other staff member to go ahead and provide the shower because it was the resident’s scheduled shower day, demonstrating that the resident’s right to refuse care and the care plan interventions to respect refusals were not followed.
Failure to Contact EMS and Use AED During CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its CPR and emergency response policy for a resident who was a documented full code. Facility policy required staff to call 911 for resident emergencies, obtain and use an AED, and initiate CPR for full code residents unless there was a POST form or other physician order to withhold CPR, or the resident showed American Heart Association (AHA) signs of clinical death. The 2020 AHA Adult Basic Life Support Algorithm directs healthcare providers to activate the emergency response system, obtain an AED, and use it as soon as available when a person has no breathing or only gasping and no pulse. The facility had two AEDs and staff were educated on AED use as part of CPR training. Resident #78 was admitted for rehabilitation and 24-hour skilled nursing care following a hospitalization due to a fall at home and had a medical history including atrial fibrillation with multiple cardioversions, dysphagia, chronic kidney disease, mild cognitive impairment with memory loss, hypertension, UTI, influenza, and type 2 diabetes mellitus. The resident’s profile, care plan, and physician’s orders all documented full code status. A 5-day MDS showed a BIMS score of 4, indicating severe cognitive impairment. On the evening prior to the event, an RN documented that the resident was sitting in a wheelchair watching television at 8:20 PM, was assisted to the bathroom at 10:00 PM, and was checked again at 12:00 AM. At approximately 2:00 AM, a CNA found the resident unresponsive and notified the RN, who assessed the resident and documented no heart sounds, pulse, or respirations. Staff initiated CPR and continued efforts until the RN pronounced the resident deceased at 2:45 AM. There was no documentation in the medical record that EMS/911 was contacted or that an AED was used during the resuscitation attempt, despite facility policy and the expectations stated by the DON, LPN, NP, and Medical Director that staff should call 911, obtain and use an AED, and continue CPR until EMS arrival for a full code resident. An email from the local fire department indicated there were no EMS reports for the resident on the date in question, and the DON stated she had no evidence to verify that EMS was contacted and no AED log to show whether an AED was used. The Administrator stated she expected staff to follow the CPR policy and properly document all care and services provided, but the record lacked evidence of EMS notification or AED utilization for this full code resident.
Failure to Activate and Follow Sliding Scale Insulin and Blood Glucose Orders
Penalty
Summary
The deficiency involves the facility’s failure to activate and carry out physician orders for blood glucose monitoring and sliding scale insulin for a resident with type 2 diabetes. Facility policy on insulin administration required verification that insulin type, dosage, strength, and method of administration corresponded with the physician’s order, checking blood glucose per physician order or facility protocol, and documenting blood glucose results and insulin doses. The resident’s care plan for diabetes directed staff to check blood sugar levels via fingerstick per physician orders and to administer medications per physician orders. The resident was admitted for rehabilitation and 24-hour skilled nursing care following a hospitalization due to a fall at home and had a medical history that included chronic kidney disease and type 2 diabetes mellitus. A 5-day MDS showed severe cognitive impairment with a BIMS score of 4 and an active diagnosis of type 2 diabetes, with insulin injections received. Physician orders directed staff to check the resident’s blood sugar before meals and at bedtime, four times a day, and to administer insulin aspart via a sliding scale four times a day. These orders were in place with a specified stop date and then renewed. Despite these orders, the medication record for the resident showed no documentation of blood sugar levels or administration of insulin aspart at multiple ordered times over several days. A family member reported concern that the resident’s blood sugar levels had not been checked for the past couple of days and that the resident was not on a short-acting insulin. A medication error report later identified that the NP had updated the sliding scale insulin order, but the update was not signed and remained in the unsigned order queue, leaving the insulin aspart order inactive on the MAR. As a result, nursing staff could not see the updated order and missed multiple doses of insulin aspart. The NP stated that she had intended to edit, not discontinue, the sliding scale order, but the electronic medical record required her to unsign the order to edit it, and she failed to reactivate it. The DON stated that nursing staff failed to identify that the insulin aspart order was missing and remained in the queue awaiting reactivation, and the Administrator stated that her expectation was for staff to follow company policy and for the DON or designee to verify that all active orders were visible for nurses when a plan of correction for missing insulin doses had been implemented. A physician statement documented that the resident had uncontrolled type 2 diabetes mellitus, CKD stage III, and hyperlipidemia, and that the resident received sliding scale insulin on one day but did not receive any sliding scale insulin on the following two days. The physician noted that the resident’s blood glucose reached a maximum level of 343 mg/dL during this period and that the sliding scale insulin order was later replaced and resumed. These findings collectively show that the facility did not provide treatment and care according to physician orders and the resident’s care plan for diabetes management, due to the failure to activate and monitor the sliding scale insulin and blood glucose orders in the electronic system and to recognize and correct the missing active order on the MAR.
Failure to Maintain Clean and Sanitary Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean and sanitary environment in multiple resident rooms and bathrooms, contrary to its own policies on routine bathroom cleaning and routine cleaning and disinfection. The facility’s policies, dated 6/2025, required providing a clean and sanitary environment, cleaning the entire toilet including the handle and underside of the flush rim with disinfectant and appropriate contact time, and reporting damaged items in need of repair. Observations conducted on several days showed that in one room, a motorized wheelchair had dried debris on the cushion, arms, and a large amount of multi-colored debris on the undercarriage. In another room, a wheelchair with a fabric heel protector cushion used as an armrest was spattered with small to pea-sized unknown multi-colored particles. Additional observations revealed that several resident bathrooms were not maintained in a sanitary condition. One bathroom had a trash can without a bag and with a dried brown substance on the outside, rim, and inside of the can, as well as a toilet seat with two areas of dried yellow residue and a yellow/orange substance around the base of the toilet. Other bathrooms in different rooms had yellow/orange or brown residue around or at the front base of the toilets. During an observation and interview in one of the bathrooms, the Administrator initially suggested the substance around the toilets might be related to the wax ring, but after wiping a small area with a wet wipe, the yellow/orange substance was easily removed, and the Administrator confirmed the area around the toilet was not clean.
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