Alta Heights Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Goodlettsville, Tennessee.
- Location
- 813 S Dickerson Rd, Goodlettsville, Tennessee 37072
- CMS Provider Number
- 445460
- Inspections on file
- 19
- Latest survey
- February 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Alta Heights Post Acute during CMS and state inspections, most recent first.
The facility failed to properly label, date, and store food items in the kitchen and the 300 Hall nourishment room. Opened containers of chicken salad and pimento cheese were not dated, and raw bacon was left uncovered on the countertop. In the nourishment room, grapes, oranges, and juice were found unlabeled and undated. The Admission Nurse incorrectly stated that juice could remain open until the expiration date, contrary to policy.
The facility failed to maintain infection control practices, with LPNs not cleaning equipment, using protective barriers, or wearing PPE in enhanced barrier precaution rooms. Observations included improper hand hygiene and equipment disinfection, affecting residents with severe cognitive impairment and chronic diseases.
The facility failed to maintain a safe and sanitary environment, with deficiencies observed in 11 rooms, including broken furniture, exposed screws, and strong odors. Interviews confirmed the need for repairs and replacements, and staff acknowledged issues with room conditions and odors. Despite daily cleaning, some rooms remained cluttered and malodorous, with no further actions taken.
The facility failed to provide adequate hot water for resident bathing, affecting three residents. Observations showed water temperatures below the required range, with residents and CNAs reporting cold water during bed baths. The Maintenance Director noted the hot water system's inefficiency, requiring multiple bathrooms to run water simultaneously to reach the desired temperature. Despite awareness of the issue, the facility did not ensure compliance with water temperature standards.
A resident with intact cognitive abilities experienced a breach of privacy when two CNAs entered her room without knocking during a surveyor interview. The facility's policy requires staff to treat residents with respect and ensure their privacy, which was not adhered to in this instance. The resident expressed dissatisfaction with the lack of respect shown by the CNAs.
A resident with severe cognitive impairment reported being spun around in his wheelchair by a staff member, resulting in a fractured arm. The incident, related to a disagreement over room temperature, was reported to the DON but not to state agencies as required. The resident's family confirmed the injury, and the staff member was later identified and terminated for unrelated reasons.
The facility failed to update care plans for two residents, one with a DNR status not reflected in their care plan and another with a recent leg fracture lacking specific transfer interventions. The DON confirmed these oversights, and the Rehab Director noted a lack of recent evaluation for one resident.
A resident with moderately impaired cognition was not provided adequate assistance with ADLs, including toileting hygiene and facial hair removal, despite her care plan indicating a need for such support. Observations showed the resident in a soiled brief and with facial hair she wanted removed, but staff did not offer assistance. The DON confirmed staff should notify the charge nurse and document refusals, but this was not done, leading to a deficiency.
A resident with severe cognitive impairment and a high risk for elopement left the facility unsupervised, resulting in a fall and minor injuries. Despite documented wandering behaviors and confusion, the care plan lacked specific interventions to prevent elopement. The resident was found by EMS after falling on a sidewalk, highlighting the need for improved supervision and care planning.
A resident with a history of thrombosis and embolism was prescribed Eliquis, an anticoagulant, but the facility failed to monitor for bleeding as required by their anticoagulation policy. The resident's Medication Administration Records for several months showed no monitoring for bleeding, which was confirmed by the DON.
Two LPNs in an LTC facility failed to properly administer medications, resulting in a 12.5% error rate. One resident received Levothyroxine and Potassium Chloride ER incorrectly via PEG tube, while another resident's Carbidopa-Levodopa was improperly crushed and administered. The DON confirmed these actions were against facility policy.
The facility failed to ensure proper medication storage, as LPNs left medication carts unlocked and medications unattended during administration. An LPN admitted to leaving a treatment cart unlocked, and medications were found on a resident's over-the-bed table. The DON confirmed these actions were against policy.
Improper Food Labeling and Storage
Penalty
Summary
The facility failed to adhere to its own policies regarding the labeling, dating, and storage of food items, both in the kitchen and in the 300 Hall nourishment room. During an initial kitchen walk-through, surveyors observed an opened container of chicken salad and an opened container of pimento cheese, neither of which were labeled with an open date or a use-by date. The Dietary Manager confirmed that these items should have been dated. Additionally, four uncovered pieces of raw bacon were found lying on the countertop, which is not in accordance with proper food storage practices. In the 300 Hall nourishment room, surveyors found an unlabeled and undated bag of grapes, an opened and undated bag of oranges, and an undated and opened container of juice in the refrigerator. The Admission Nurse incorrectly stated that juice could remain open in the refrigerator until the manufacturer's expiration date, contrary to the facility's policy that requires opened beverages to be discarded after 24 hours. The nurse also acknowledged that all items in the refrigerator should be labeled with the resident's name, which was not done in this case.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain infection prevention and control practices, as evidenced by multiple observations of staff not adhering to established protocols. Three nurses, identified as LPN O, LPN W, and LPN X, did not clean reusable equipment before and after use and failed to use protective barriers. Additionally, LPN X did not wear Personal Protective Equipment (PPE) in enhanced barrier precaution rooms, which is a requirement according to the facility's policy. Specific incidents included LPN O administering eye drops to a resident without performing hand hygiene between treating each eye, and failing to disinfect equipment such as a blood pressure machine and eye drop bottles after use. LPN O also did not use a protective barrier when placing medications on an over bed table. Similarly, LPN W and LPN X were observed placing items on over bed tables without protective barriers and not wearing PPE in rooms designated for enhanced barrier precautions. The report highlights the facility's policy failures, including the lack of adherence to hand hygiene protocols and the improper use of PPE. Interviews with staff, including the Director of Nursing and the Infection Control Preventionist, confirmed that these practices were not in line with the facility's infection control policies. The deficiencies were observed in residents with various medical conditions, including severe cognitive impairment, cerebral infarction, and chronic diseases, which could increase their vulnerability to infections.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for residents, as evidenced by numerous deficiencies observed in 11 of 48 occupied rooms. These deficiencies included broken or missing pieces on window blinds, exposed sharp screws on closet doors, holes in walls, missing hooks from privacy curtains, and air conditioners with missing front panels and filters. Additionally, there were issues with furniture, such as bulging and missing pieces from overbed tables, missing laminate pieces from dressers and nightstands, and peeling plaster from walls. A broken bed with no mattress was stored in a resident's room, and strong malodorous odors were present in some residents' rooms. Interviews with the Maintenance Supervisor confirmed the need for repairs and replacements in several rooms, including replacing dressers, repairing walls, and attaching cable cord boxes to walls. The Maintenance Director acknowledged issues with a broken shower and loose toilet seat in one resident's room, and the Administrator admitted to being unaware of a broken bed being stored in a resident's room. Housekeeping staff reported no special provisions to address wound-related odors, and the Environmental Supervisor noted a delay in receiving a specialty cleaner to help with the smell. The report highlights the facility's failure to provide a homelike environment, as confirmed by the Administrator, who acknowledged that the conditions observed did not meet this standard. The presence of strong odors, particularly in the room of a resident with skin cancer and copious wound drainage, was noted, with staff indicating that the smell was a known issue. Despite daily cleaning efforts, some rooms remained cluttered and malodorous, with no further actions taken to address these conditions.
Failure to Provide Adequate Hot Water for Resident Bathing
Penalty
Summary
The facility failed to provide reasonable accommodations for the water temperature needs of three residents during bathing activities. The facility's policy and state regulations require hot water to be available at temperatures between 105°F and 115°F at all times. However, observations and interviews revealed that the water temperature in the bathrooms of the affected residents was significantly below the required range, with temperatures recorded at 78°F and 97°F. Residents reported that the water was cold during bed baths, and CNAs confirmed that they had to let the water run for extended periods to try to achieve a warm temperature, often without success. The Maintenance Director explained that the hot water system on the 100 and 200 halls required multiple bathrooms to be running water simultaneously to reach the desired temperature, which was not always feasible. The Social Service Director acknowledged resident complaints about cold water, and the Administrator admitted that staff and residents should not have to wait for hot water. Despite awareness of the issue, the facility did not ensure that the water temperature met the required standards, leading to discomfort and dissatisfaction among residents.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to provide privacy for a resident, identified as Resident #28, during an incident involving two Certified Nursing Assistants (CNAs). The facility's policy on resident rights emphasizes the importance of treating residents with respect, kindness, and dignity, including ensuring their privacy and confidentiality. Resident #28, who has intact cognitive abilities as indicated by a Brief Interview for Mental Status (BIMS) score of 15, was admitted with diagnoses including Hypertensive Heart Disease, Anemia, Hyperlipidemia, and Atherosclerotic Heart Disease. During an observation, two CNAs entered Resident #28's room without knocking or asking for permission while a surveyor was conducting an interview. This action occurred immediately after the resident was asked if she felt treated with respect and dignity, to which she responded negatively after the CNAs entered unannounced. The facility administrator later confirmed that CNAs are expected to knock before entering a resident's room.
Failure to Report Allegation of Abuse Resulting in Injury
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who was admitted with multiple diagnoses, including cerebral infarction, dementia, and a fractured upper humerus. The incident occurred when the resident reported to his family that a staff member had taken him by the arm and spun him around in his wheelchair, which was related to a disagreement over the room's air conditioning. Despite the resident's severe cognitive impairment, he was able to identify the staff member involved after being shown several staff members. The incident was reported to the Director of Nursing by the resident's family, but it was not reported to state agencies as required. The resident's family confirmed that the resident complained of shoulder pain and numbness following the incident, and an x-ray later revealed a fracture in the right arm. The facility's investigation included a timeline of events, but the incident was not classified as an allegation of abuse or an injury of unknown origin, and thus was not reported to the appropriate authorities. The staff involved was later terminated for unrelated issues, and the facility educated staff on proper repositioning techniques, but these actions were not part of the initial response to the incident.
Failure to Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to revise comprehensive care plans for two residents, leading to deficiencies in their care. Resident #3, who was admitted with multiple diagnoses including Chronic Obstructive Pulmonary Disease and Anxiety Disorder, had a documented DNR status that was not reflected in their care plan. The Director of Nursing confirmed the absence of a DNR order in the care plan during an interview, and the order was only added after the oversight was identified. Resident #64, admitted with conditions such as Cerebral Infarction and Hemiplegia, experienced a fracture to the left leg that was not addressed in their care plan. Despite the resident's need for assistance with ADLs and the use of an immobilizer brace, the care plan lacked specific interventions for safe transfers. The Rehab Director acknowledged that the resident had not been evaluated since July 2024, and the DON confirmed the care plan did not reflect the recent fracture or necessary transfer protocols.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate care and services related to activities of daily living (ADLs) for a resident with moderately impaired cognition. The resident, who was admitted with diagnoses including diabetes, hypertension, vitamin D deficiency, and cognitive communication deficit, required assistance with toileting hygiene and personal hygiene. Observations revealed that the resident was left in a soiled incontinent brief and had facial hair that she wanted removed, but staff did not offer assistance. The resident's care plan indicated a need for daily assistance with morning and evening care, including oral and grooming tasks, as well as toileting hygiene and incontinent care. Interviews with staff revealed that the resident often refused care, but the Certified Nursing Assistant (CNA) did not report these refusals to the nurse. The Director of Nurses (DON) confirmed that staff should notify the charge nurse, document refusals, and attempt different approaches if a resident refuses care. Despite the resident's expressed desire to have her facial hair removed, staff failed to recognize and address this need. The DON acknowledged that staff are expected to offer assistance in such situations, but this was not done, leading to a deficiency in the resident's care.
Resident Elopement and Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent an elopement incident involving a resident identified as being at high risk for wandering and elopement. The resident, who had a history of traumatic brain injury, lung cancer, and other significant medical conditions, was admitted with a high risk for elopement due to addiction-related behaviors. Despite this, the resident's care plan lacked specific interventions to address the elopement risk, and the resident was able to leave the facility unsupervised, resulting in a fall and minor injuries. The resident's medical records indicated a severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 5, and a history of wandering behaviors that intruded on the privacy of others. The resident exhibited confusion, agitation, and difficulty with redirection, as noted in multiple nursing progress notes. Despite these documented behaviors, the facility's care plan did not include adequate measures to prevent elopement, such as increased supervision or the use of assistive devices. On the day of the incident, the resident eloped from the facility and was found by emergency services after falling on a sidewalk. The resident was confused and had minor injuries, including a laceration on the toe and an abrasion on the arm. The emergency department report noted the resident's confusion and history of substance abuse, highlighting the need for a more comprehensive and effective care plan to prevent such incidents in the future.
Failure to Monitor Anticoagulant Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications by not monitoring for potential complications associated with the use of an anticoagulant. The facility's policy on anticoagulation required staff and physicians to identify and address potential complications and monitor for possible complications. However, for a resident with a history of thrombosis and embolism, who was prescribed Eliquis, an anticoagulant, there was no monitoring for bleeding documented in the Medication Administration Records for December 2024, January 2025, and February 2025. The resident, who had intact cognition and was receiving multiple medications including an anticoagulant, was not monitored for bleeding and bruising as confirmed by the Director of Nursing during an interview.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than 5%, resulting in a 12.5% error rate. This was due to improper medication administration by two LPNs for two residents. One resident, with diagnoses including esophagus cancer and dysphagia, had a physician's order for Levothyroxine to be administered via PEG tube at bedtime and Potassium Chloride ER to be given by mouth. However, the LPN crushed and administered both medications incorrectly, leading to a clogged PEG tube and a deviation from the prescribed administration method. Another resident, diagnosed with conditions such as Tourette's Disorder and chronic kidney disease, had an order for Carbidopa-Levodopa to be given by mouth. The LPN crushed the tablet and administered it via PEG tube without proper dilution, contrary to the order. Interviews with the DON confirmed that these practices were not in line with the facility's medication administration policies, contributing to the medication errors observed.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medications, as evidenced by several incidents involving Licensed Practical Nurses (LPNs) leaving medication storage areas unlocked and unattended. During a random observation, an LPN was found to have left a treatment cart unlocked and unattended in the 100 Hall. The LPN acknowledged the oversight, admitting that the cart should have been locked. Additionally, medications were observed left on an over-the-bed table in a resident's room, which was confirmed by the Director of Nursing (DON) as inappropriate storage. Further observations revealed that two LPNs left medications unattended and out of sight during medication administration. One LPN left pills and eye drops unattended while retrieving gloves and washing hands, while another LPN left medications unattended while getting water. Both LPNs admitted that they should not have left the medications unattended. The DON confirmed that medications should be stored in a way that is inaccessible to others, highlighting the facility's failure to adhere to its medication storage policy.
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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