Ahc Lexington
Inspection history, citations, penalties and survey trends for this long-term care facility in Lexington, Tennessee.
- Location
- 727 East Church Street, Lexington, Tennessee 38351
- CMS Provider Number
- 445431
- Inspections on file
- 22
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Ahc Lexington during CMS and state inspections, most recent first.
The facility failed to inform residents about their rights to refuse treatment and formulate advance directives, affecting 11 residents with various medical conditions. Despite the facility's policy, the required sections of the Consent and Authorizations forms were not initialed, indicating a lack of information provided. The administrator confirmed this oversight, highlighting a systemic issue in the facility's process.
The facility failed to maintain sanitary conditions in its food service operations, with unsanitary kitchen conditions and inadequate dishwashing practices. Observations revealed dirt, debris, and food particles on containers, a greasy oven and vent hood, and rusty utensil drawers. The dish machine consistently failed to reach the required sanitation temperature, and the facility lacked sufficient emergency food stock. These issues were confirmed by the Dietary Manager and Registered Dietitian.
A resident with multiple diagnoses, including COPD, was left unattended with a running nebulizer, contrary to facility policy requiring nurse supervision during medication administration. The resident, who was cognitively intact, had no evaluation for self-administration of medication, as confirmed by the DON.
A resident reported a sexual assault by a CNA during a bed bath, but the facility failed to report the allegation to the appropriate authorities as required by policy. The Administrator conducted an initial investigation before deciding not to report, contrary to the policy of immediate reporting within two hours.
A resident reported a sexual abuse allegation against a CNA, but the facility failed to conduct a thorough investigation as per its policy. The investigation lacked detailed documentation and did not include all required interviews and reviews. The Administrator believed the steps taken were sufficient, despite the incomplete investigation process.
Two residents did not receive scheduled showers as per the facility's policy, leading to a deficiency in care. One resident, moderately cognitively impaired, missed multiple showers over several weeks, while another, cognitively intact, reported receiving showers only every two weeks. The DON confirmed the lapses in scheduled care.
A facility failed to follow infection control practices when a nurse did not wear PPE during medication administration via peg tube for a resident under enhanced barrier precautions, and a CNA did not perform hand hygiene during catheter care for a cognitively impaired resident. The DON confirmed the lapses in protocol adherence.
The facility failed to employ a qualified dietician, leading to deficiencies in kitchen sanitation, staff competencies, and meal delivery. Residents did not receive meals that met their dietary needs, with reports of late, incomplete, or inadequate meals. The kitchen was found in poor sanitary condition, with untrained staff performing duties due to a lack of leadership and consistent staffing.
The facility failed to provide sufficient and properly trained staff for its food and nutrition services, leading to incomplete dish machine logs and late meal deliveries. The Administrator and other non-dietary staff had to work in the kitchen due to understaffing, resulting in disorganized operations. Residents reported receiving meals late, and many staff members lacked the necessary training to perform kitchen duties effectively.
The facility's kitchen was found to be unsanitary, with dietary staff not covering facial hair, dirty floors, and unclean equipment. Dish machine temperatures and sanitizer levels were not consistently checked or recorded, and cleaning schedules were not followed. Interviews with staff revealed a lack of leadership and accountability in maintaining cleanliness.
The facility failed to provide a nourishing and well-balanced diet to its residents, as evidenced by three residents not receiving meals that met their nutritional needs. A resident at risk for weight loss did not receive prescribed double portions, and the facility was unable to provide menu items due to a delay in food delivery. Staff and residents reported issues with meal quality, portion sizes, and late meal delivery, highlighting disorganization and staffing issues in the kitchen.
Failure to Provide Advance Directive Information to Residents
Penalty
Summary
The facility failed to provide information to residents regarding their right to refuse medical or surgical treatment or to formulate an advance directive. This deficiency was identified for 11 out of 24 residents reviewed for advance directives. The facility's policy, dated September 2022, requires that the social services director or designee inquire about the existence of any written advance directives upon admission and provide written information concerning the right to refuse or accept treatment and to formulate an advance directive. However, the review of medical records revealed that the required sections of the Consent and Authorizations forms were not initialed or signed, indicating that residents or their representatives were not given the necessary information or assistance regarding advance directives. The deficiency involved residents with various medical conditions, including rheumatoid arthritis, atrial fibrillation, heart failure, hypertension, dementia, anxiety, depression, Alzheimer's disease, multiple sclerosis, and traumatic brain injury. The cognitive status of these residents varied, with some being cognitively intact and others severely impaired, as indicated by their Brief Interview for Mental Status (BIMS) scores. Despite these differences, the facility consistently failed to document that residents or their representatives received education about advance directives, as evidenced by the lack of initials on the Consent and Authorizations forms. During an interview, the facility's administrator confirmed that the Consent and Authorizations forms should have been initialed to indicate that residents or their responsible parties received education about advance directives. This oversight highlights a systemic issue in the facility's process for ensuring that residents are informed of their rights regarding medical treatment and advance directives, as required by their own policy.
Sanitation and Food Service Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in its food service operations, as evidenced by multiple observations and policy reviews. The kitchen was found to have unsanitary conditions, including dirt, debris, and dead insects on food cartons, sticky and dirty containers, and food particles on the outside of containers. The oven and grease trap were observed with significant build-up of grease and food particles, and the vent hood was greasy and dirty. Additionally, utensils were stored in rusty drawers, and food items were undated and unlabeled in dirty containers. These conditions were confirmed by the Dietary Manager and Registered Dietitian, who acknowledged that the kitchen should not be in such a state. Furthermore, the facility's dishwashing practices were inadequate, with the low temperature dish machine consistently failing to reach the required 120 degrees Fahrenheit for proper sanitation. The dish machine logs showed repeated instances of wash temperatures below the required level, and staff failed to cease use of the machine despite these inadequate temperatures. Additionally, the facility did not have sufficient food stock for a 72-hour emergency menu, as confirmed by the Registered Dietitian, who noted missing food items and the need to order additional supplies. These deficiencies indicate a failure to adhere to professional standards for food storage, handling, preparation, and service.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, specifically concerning the use of a nebulizer. The facility's policy on administering medications through a nebulizer requires a nurse to be present during the administration and to ensure the nebulizer is turned off and put away after use. However, observations revealed that the resident was left unattended with the nebulizer running in their lap for an extended period, indicating a lack of supervision and adherence to the facility's policy. The resident involved was admitted with multiple diagnoses, including Rheumatoid Arthritis, Atrial Fibrillation, Heart Failure, and Hypertension, and was cognitively intact with a BIMS score of 15. The resident had a physician's order for Ipratropium/Albuterol inhalation solution to be administered four times a day for Chronic Obstructive Pulmonary Disease. Despite this, the Director of Nursing confirmed that there was no evaluation for the resident's ability to self-administer medication, and a nurse should have been present during the administration.
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to all appropriate local and state agencies. According to the facility's policy, any reports of resident abuse must be reported to local, state, and federal agencies within two hours of the allegation. However, the facility did not adhere to this policy when a resident, who was cognitively intact and dependent on staff for personal care, reported a sexual assault by a Certified Nursing Assistant (CNA) to the Assistant Director of Nursing (ADON). The resident alleged inappropriate touching during a bed bath, which was not reported to the necessary authorities as required. The Administrator, who also served as the Abuse Coordinator, confirmed that an initial investigation was conducted before any report was made to the State Agency. The Administrator's interpretation of a 'true allegation' required a suspicion to be confirmed before reporting, which led to the failure to report the incident immediately. The CNA involved denied the allegations, and the resident was appeased by removing the CNA from her care. This approach was contrary to the facility's policy, which mandates immediate reporting of any abuse allegations, regardless of the initial investigation's findings.
Inadequate Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a resident who was cognitively intact and dependent on staff for various activities. The resident reported to the Assistant Director of Nursing (ADON) that a Certified Nursing Assistant (CNA) had inappropriately touched her during a bed bath. The facility's policy requires a comprehensive investigation, including interviews with the resident, the accused, and any witnesses, as well as a review of the resident's medical records and interactions. However, the investigation was insufficient, as evidenced by the lack of a detailed and dated documentation of the investigation process. The Administrator provided a one-page undated witness statement and additional documents that did not meet the facility's policy requirements for a thorough investigation. The Administrator admitted to interviewing the resident and the CNA and instructed the CNA to avoid the resident's room, but there was no evidence of a complete investigation as outlined in the policy. The Administrator's response indicated a belief that the steps taken were appropriate, despite the lack of comprehensive documentation and adherence to the facility's policy on abuse investigations.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL), specifically showering, for two residents. According to the facility's policy, residents who cannot independently perform ADLs should receive necessary services to maintain personal hygiene. However, Resident #41, who was moderately cognitively impaired and required partial assistance with bathing, did not receive showers on multiple scheduled dates in January and February 2025. This was confirmed by the resident, who kept a personal record of her shower dates and reported not receiving a shower for two weeks in January. Similarly, Resident #45, who was cognitively intact and also required partial assistance with bathing, reported receiving showers only every two weeks, contrary to the facility's schedule of three times a week. The Director of Nursing confirmed that residents should receive showers on their assigned dates and acknowledged the missing dates. These findings indicate a failure to adhere to the facility's policy on providing necessary ADL assistance, resulting in a deficiency in resident care.
Infection Control Lapses During Medication and Catheter Care
Penalty
Summary
The facility failed to adhere to its infection control practices during medication administration and catheter care, as observed in two separate incidents. In the first incident, a Registered Nurse (RN) did not wear the required personal protective equipment (PPE) while administering medication via a peg tube to a resident who was under enhanced barrier precautions. This resident had a medical history that included Wernicke's Encephalopathy, Diabetes, Dysphagia, Gastrostomy, and Respiratory Failure, and was assessed for a feeding tube. The facility's policy required the use of gloves and gowns for such procedures, but the RN was observed administering medication without a gown. In the second incident, a Certified Nursing Assistant (CNA) failed to perform hand hygiene during foley catheter care for a resident with a history of Heart Failure, Multidrug-Resistant Organism, Urinary Tract Infection, Malnutrition, and Diabetes. The resident was severely cognitively impaired and dependent on staff for various activities. The CNA was observed removing soiled gloves and donning new ones without performing hand hygiene, contrary to the facility's hand hygiene policy. The Director of Nursing confirmed that the staff should have adhered to the infection control protocols in both cases.
Deficiencies in Dietary Services and Kitchen Sanitation
Penalty
Summary
The facility failed to employ a Registered Dietician (RD) or Qualified Nutritional Professional to oversee the food and nutrition services, leading to significant deficiencies in kitchen sanitation, staff competencies, and the timely delivery of meals. The absence of a qualified professional resulted in inadequate oversight of kitchen operations, including the failure to maintain proper cleaning and sanitizing protocols, as evidenced by incomplete dish machine temperature logs and unperformed cleaning duties. Additionally, the facility's policies regarding dietary services, such as ensuring meals meet residents' nutritional needs and are delivered on time, were not adhered to. The report highlights several instances where residents did not receive meals that met their prescribed dietary needs. For example, a resident with a history of weight loss and a regular diet order with double portions did not receive the appropriate meal portions due to a lack of food availability and staff shortages. Observations revealed that meals were often late, incomplete, or substituted with inadequate alternatives, such as missing menu items like waffles and chocolate chip cookies. Interviews with residents and staff confirmed ongoing issues with meal quality and timeliness, exacerbated by the facility's inability to maintain consistent kitchen staffing and leadership. Furthermore, the facility's kitchen was found to be in poor sanitary condition, with observations of dirty floors, unclean equipment, and staff not adhering to hygiene protocols, such as wearing facial coverings. The lack of a Certified Dietary Manager (CDM) and the reliance on untrained staff, including the Administrator and housekeeping personnel, to perform kitchen duties contributed to the disorganization and failure to meet regulatory standards. The facility's inability to provide adequate training and maintain a clean and organized kitchen environment further compromised the quality of care provided to residents.
Staffing and Training Deficiencies in Food and Nutrition Services
Penalty
Summary
The facility failed to provide sufficient staff with the necessary competencies and skill sets to effectively carry out the functions of the food and nutrition services. This deficiency was observed in 12 out of 17 staff members, including dietary aides, CNAs, housekeepers, and even the Director of Nursing and the Administrator, who were working in the kitchen. The facility had a census of 78 residents, with 76 receiving meal trays from the kitchen. The lack of trained staff led to incomplete dish machine temperature logs and sanitizer checks, as well as late meal deliveries. Observations and interviews revealed that the facility's kitchen was understaffed and lacked proper leadership following the firing of the previous Certified Dietary Manager in September 2024. The Administrator had to step in to work in the kitchen, logging 600 hours, and even purchasing food from Walmart due to delivery issues. Meal times were consistently late, with reports of breakfast being served as late as 9:00 AM, lunch at 2:00 PM, and supper at 6:30 PM. Residents confirmed that their meals were often delayed, with one resident stating that lunch was served as late as 2:00 PM. The deficiency was further compounded by the fact that many staff members working in the kitchen were not officially trained for their roles. Housekeepers and CNAs were asked to assist in the kitchen, but they lacked the necessary training to perform tasks such as checking dish machine temperatures and using sanitizer strips. The Director of Nursing and the Administrator confirmed that the kitchen staff was not fully trained, and the absence of a Certified Dietary Manager led to a lack of leadership, resulting in disorganized operations and late meal services.
Sanitation and Food Handling Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by multiple observations of unclean equipment and improper food handling practices. Dietary staff were observed not wearing facial coverings to cover facial hair, and the kitchen floor was consistently dirty with scattered paper and debris. Additionally, cookware, including skillets and pans, had significant black sticky buildup, and the convection oven contained dried food particles and a thick brown sticky substance. Metal storage racks were found to be rusty with peeling metal and dust buildup. The facility also failed to adhere to its own policies regarding dishwashing and sanitation. The dish machine temperature logs for November and December 2024 were incomplete, with numerous instances where temperatures and sanitizer levels were not checked or recorded. This lack of documentation was confirmed by the Administrator, who was unable to locate the kitchen sanitation logs for September and October 2024. Furthermore, the cleaning schedule for the kitchen was not followed, with multiple blank areas indicating that cleaning duties were not performed by the AM aide, cook, and PM aide on numerous days. Interviews with various staff members, including the Certified Dietary Manager (CDM) from another facility, the Housekeeping and Laundry Supervisor, the Director of Nursing (DON), and a Certified Nursing Assistant (CNA), revealed a lack of leadership and accountability in maintaining kitchen cleanliness. The CDM acknowledged the presence of bad habits and the need for constant supervision to ensure adherence to cleaning schedules. The DON and Administrator confirmed that the kitchen was not clean and that dish machine temperatures and sanitizer levels should be checked and documented regularly.
Failure to Provide Adequate Nutrition and Meal Portions
Penalty
Summary
The facility failed to provide a nourishing and well-balanced diet that meets the daily nutritional and dietary needs of its residents. This deficiency was observed in three residents who were reviewed for nutrition. The facility's policy on dietary menus and adequate nutrition was not adhered to, as evidenced by the failure to provide meals that met the nutritional needs of the residents. Resident #2, who was at risk for weight loss, did not receive the prescribed double portions of meals, and the facility was unable to provide the menu items due to a delay in food delivery. The resident expressed concerns about the quality and consistency of meals, and the facility's inability to provide the prescribed diet was confirmed by staff observations and interviews. The facility's kitchen operations were disorganized, leading to inconsistencies in meal preparation and delivery. Observations revealed that residents did not receive the menu items as planned, and substitutions were made due to a lack of available food. Staff interviews confirmed that residents received smaller portions than prescribed, and the facility struggled with staffing issues in the kitchen. The lack of a dietary manager and consistent kitchen staff contributed to the failure to meet the residents' nutritional needs. Interviews with staff and residents highlighted ongoing issues with meal quality and portion sizes. Residents reported receiving meals late and expressed dissatisfaction with the food provided. Staff confirmed that the facility did not have enough food to meet the prescribed portions, and the Director of Nursing acknowledged the need for better kitchen management and planning. The Administrator confirmed that there were complaints about food shortages and that efforts were made to address the issue temporarily by purchasing groceries. However, the deficiency persisted, affecting the residents' nutritional intake and overall satisfaction with the facility's dietary services.
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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