Avondale Health And Rehabilitation Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Humboldt, Tennessee.
- Location
- 2031 Avondale Street, Pobox 446, Humboldt, Tennessee 38343
- CMS Provider Number
- 445454
- Inspections on file
- 16
- Latest survey
- January 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Avondale Health And Rehabilitation Center, Llc during CMS and state inspections, most recent first.
The facility did not adhere to its policy of posting daily nurse staffing information, as required. The policy specifies that the facility must display the total number and actual hours worked by RNs, LPNs, and CNAs per shift. However, from early December to early January, the facility's Daily Nurse Staffing forms lacked this information. The Staffing Coordinator confirmed the omission during an interview.
The facility failed to employ a full-time or part-time RD or qualified DM, affecting 55 residents receiving meals. The RD's responsibilities included ensuring dietary compliance and monitoring residents' nutritional status. Since the week of Christmas, the facility lacked an RD, and the Dietary Supervisor was still obtaining certification. Interviews revealed confusion about the RD's role, with an Interim RD contracted but not yet engaged with staff.
The facility failed to provide sufficient staff with the necessary competencies to effectively carry out food and nutrition services, impacting meal preparation and delivery for 55 residents. Despite awareness of staffing concerns, the facility could not provide competency documentation for kitchen staff, leading to delays in meal service.
The facility failed to maintain sanitary conditions in food storage, handling, preparation, and service. Dietary staff did not adhere to hand hygiene protocols, with instances of serving food without gloves and failing to wash hands after potential contamination. The kitchen contained improperly labeled, undated, and expired food items, and the 3 compartment sink was not properly sanitized before use. The Dietary Supervisor confirmed these deficiencies, indicating a failure to follow facility policies.
The facility failed to follow infection control practices during medication administration and resident care. An LPN dropped medication on an unprotected surface and intended to administer it, while another LPN did not use a gown during PEG tube medication administration. A resident on contact isolation received meals on regular trays, and an LPN used unsanitized equipment between residents. The DON confirmed these lapses in infection control practices.
A resident with multiple diagnoses, including heart failure, experienced significant weight gain over six months, but the facility failed to revise the care plan to address this change. Despite the resident's weight increasing from 156 to 180 pounds, the care plan was not updated to reflect the resident's heart failure diagnosis or the need for dietary adjustments. Interviews with facility staff confirmed that the care plan should have been revised.
The facility failed to follow physician orders for two residents. One resident with severe cognitive impairment and a history of bradycardia did not have their heart rate monitored as ordered, leading to an emergency room visit. Another resident, who refused antibiotics due to diarrhea, did not have a stool sample collected for C. diff testing as ordered. These deficiencies highlight lapses in documenting and executing physician orders.
A facility failed to maintain the dignity of a resident with an indwelling urinary catheter. Despite a physician order for a privacy bag to be used every shift, observations showed the catheter bag was visible from the hallway without a cover. The resident, who was cognitively intact and dependent on staff, had diagnoses including MS and UTI. The DON confirmed the catheter bag should always be covered to promote dignity.
A resident with heart failure and other conditions experienced significant weight gain, which was not properly assessed or communicated to the physician by the facility. Despite policies in place, the facility failed to have a Registered Dietitian reassess the weight gain or notify the physician, leading to a deficiency in care.
A facility failed to reassess the effectiveness of pain medication for a resident with multiple diagnoses, including chronic pain conditions. Despite the facility's policy requiring pain level assessments before and after medication administration, the resident's pain levels were not documented post-medication. Interviews with staff confirmed the expectation for such assessments, yet the deficiency persisted, indicating a lapse in the facility's pain management practices.
The facility failed to properly store medications in the Medication Room, as oral glucose gel was stored with external medications like hydrocortisone cream and antibiotic ointment, and nasal spray was stored with ear and eye drops without dividers. Interviews with staff confirmed these practices were against facility policy.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with its policy on posting daily nurse staffing information, as evidenced by a review of the facility's Daily Nurse Staffing forms and an interview with the Staffing Coordinator. The policy, dated December 1, 2024, mandates that the facility must make nurse staffing information readily available in a readable format to residents and visitors at any given time. This information should include the facility name, total number, and actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs) per shift. However, for the period from December 2, 2024, through January 2, 2025, the facility's Daily Nurse Staffing forms did not include the total number of RNs, LPNs, and CNAs, nor the total hours worked by these staff members. The Staffing Coordinator confirmed during an interview on January 9, 2025, that the facility had not provided the required staffing information on the Daily Nurse Staffing form.
Lack of Registered Dietitian Oversight in Facility
Penalty
Summary
The facility failed to employ a full-time or part-time Registered Dietitian (RD) or a qualified Dietary Manager (DM) to oversee the kitchen operations, staff competencies, and residents' dietary needs. This deficiency potentially affected all 55 residents receiving meals from the kitchen. The job descriptions for both the RD and DM outlined responsibilities such as ensuring compliance with dietary standards, monitoring residents' nutritional status, and overseeing meal preparation and service. However, the facility did not have an RD since the week of Christmas, and the Dietary Supervisor, who was in the process of obtaining certification, confirmed this gap in staffing. Interviews with facility staff revealed a lack of clarity and communication regarding the RD's role and responsibilities. The Administrator was unsure about the current RD's identity and whether they had been onsite, while the Director of Nursing confirmed the former RD's last day was 12/27/2024. An Interim RD was contracted during the week of 1/5/2025 but had not yet communicated with the Administrator or nursing staff about resident concerns. This lack of oversight and communication could impact the nutritional care and meal service provided to the residents.
Inadequate Staffing 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 four staff members, including three dietary cooks and a dietary supervisor, who were responsible for preparing and serving meals to all 55 residents. The facility's policies on food safety, handwashing, and manual warewashing were reviewed, revealing requirements for safe food handling and hygiene practices. However, during an observation, it was noted that only two kitchen staff members were present to cook and prepare the dinner meal, resulting in a delay in meal delivery. The facility's administrator acknowledged awareness of staffing concerns in the kitchen and mentioned that CNAs were cross-trained to assist. Despite this, the facility was unable to provide documentation of the kitchen staff's competencies. The dietary supervisor admitted to being behind schedule, indicating a struggle to meet the demands of meal preparation and service with the available staff. This situation highlights the facility's failure to adhere to its own policies and ensure adequate staffing levels to maintain timely and safe food service for its residents.
Sanitation and Food Handling Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, handling, preparation, and service, as evidenced by multiple observations and interviews. Dietary staff members did not adhere to hand hygiene protocols, with instances of staff failing to wash hands before handling clean dishes and after engaging in activities that could contaminate their hands. Additionally, staff were observed serving food without gloves and not performing hand hygiene after leaving and returning to the steam table. The facility's kitchen was found to have several instances of improperly labeled, undated, and expired food items. Observations revealed unlabeled and undated packages of hotdog buns, cinnamon rolls, roasted potatoes, fries, and other food items stored in the freezer and refrigerator. Expired containers of tuna salad and cucumber and onion salad were also found in the walk-in refrigerator, along with an unlabeled and undated cooked hamburger patty. Furthermore, the facility did not ensure proper sanitation of the 3 compartment sink, as one dietary staff member failed to test the sanitation solution before use, resulting in a knife being washed without proper sanitation. The Dietary Supervisor confirmed the necessity of labeling and dating food items, performing hand hygiene, and testing the sanitation of the sink prior to use, highlighting the facility's failure to adhere to its own policies and procedures.
Infection Control Lapses During Medication Administration and Resident Care
Penalty
Summary
The facility failed to adhere to infection control practices during medication administration and resident care. An LPN was observed dropping a Phenytoin capsule on an unprotected medication cart surface and then placing it into a medication cup with another medication, intending to administer both to a resident. The LPN acknowledged the error, confirming that the medications were contaminated and should have been discarded and replaced. Additionally, another LPN did not follow Enhanced Barrier Precautions while administering medications via a PEG tube, as they failed to wear a gown during the procedure. The facility also did not follow proper transmission-based precautions for a resident on contact isolation due to MRSA. Meals were delivered on regular trays instead of Styrofoam containers, as the dietary department was not informed of the resident's isolation status. Furthermore, an LPN was observed entering the resident's room without a gown, using a multi-use blood pressure machine without sanitizing it between residents, and failing to perform hand hygiene after glove removal. Interviews with the Director of Nursing and other staff confirmed the lapses in infection control practices. The DON acknowledged that medications dropped on unprotected surfaces should be discarded, and Enhanced Barrier Precautions, including gown and glove use, should be followed during PEG tube medication administration. The DON also confirmed that reusable equipment should be cleaned between residents and that staff should wear appropriate PPE when entering rooms of residents on contact precautions.
Failure to Revise Care Plan for Resident with Significant Weight Gain
Penalty
Summary
The facility failed to revise a person-centered care plan for a resident who experienced significant weight gain. The resident, who was admitted with diagnoses including Heart Failure, Coronary Artery Disease, Failure to Thrive, Diabetes, Aphasia, and Dementia, showed a steady increase in weight over several months. Despite the resident's weight increasing from 156.0 pounds to 180 pounds over a period of six months, the care plan was not updated to address this weight gain or the resident's heart failure diagnosis. The care plan initially included dietary measures such as a pureed diet and the administration of Megestrol Acetate as an appetite stimulant, but it did not reflect the resident's changing condition. Interviews with facility staff, including the Director of Nursing and the MDS Coordinator, confirmed that the care plan should have been revised in response to the significant weight gain. The Director of Nursing acknowledged the need to review the resident's weights with the provider to determine if medication adjustments were necessary. The MDS Coordinator also confirmed that a care plan revision was warranted given the resident's significant weight gain. However, these actions were not taken, resulting in a deficiency in the facility's care planning process.
Failure to Follow Physician Orders for Monitoring and Testing
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to deficiencies in care. For Resident #31, who was admitted with conditions including hypertension and severe cognitive impairment, a nurse practitioner issued a verbal order to monitor the resident's heart rate every hour for six hours due to a history of bradycardia. However, the Licensed Practical Nurse (LPN) did not document this order, and the resident's heart rate was only checked once during the shift. The Medical Director was informed of the low heart rate later in the day, and the resident was subsequently sent to the emergency room for further evaluation. For Resident #159, who was admitted with diagnoses including a Methicillin Resistant Staphylococcus Aureus Infection and a pressure ulcer, the resident refused intravenous antibiotics due to diarrhea. The Assistant Director of Nursing (ADON) noted the need to hold the antibiotics and collect a stool sample to test for Clostridium Difficile (C. diff). However, the order for the stool sample was not documented, and the sample was not collected, resulting in a failure to perform the necessary test as ordered by the provider.
Failure to Maintain Resident Dignity with Indwelling Catheter
Penalty
Summary
The facility failed to ensure the dignity of a resident with an indwelling urinary catheter. The resident, who was admitted with diagnoses including Multiple Sclerosis, Depression, Anxiety, Urinary Tract Infection, and Disorder of Bladder, was cognitively intact and dependent on staff for activities of daily living. The care plan indicated the use of an indwelling catheter, and a physician order specified that a privacy bag should be used every shift to maintain the resident's dignity. However, observations on multiple occasions revealed that the urinary catheter bag was attached to the resident's bed frame without a privacy cover, making it visible from the hallway. This was confirmed by the Director of Nursing, who acknowledged that the catheter bag should always be covered to promote dignity.
Failure to Monitor and Address Significant Weight Gain in Resident with Heart Failure
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident diagnosed with heart failure, coronary artery disease, failure to thrive, diabetes, aphasia, and dementia. The resident experienced a significant weight gain over several months, which was not adequately assessed or addressed by the facility. Despite the resident's weight increasing from 156 pounds to 180 pounds over a period of months, the facility did not have a Registered Dietitian or Qualified Nutritional Professional reassess the resident's weight gain to determine if it was due to actual weight gain or fluid retention related to heart failure. Additionally, the facility failed to notify the resident's physician or practitioner about the significant weight gain. The facility's policies on nutritional management and weight monitoring were not effectively implemented, as evidenced by the lack of timely reassessment and communication with the resident's healthcare provider. The Director of Nursing was unaware of the resident's ideal body weight and confirmed that the resident's weights were being gathered for review with the provider to determine if medication adjustments were necessary. This oversight in monitoring and addressing the resident's nutritional status and weight changes led to a deficiency in the care provided to the resident.
Failure to Reassess Pain Medication Effectiveness
Penalty
Summary
The facility failed to reassess the effectiveness of pain medication for a resident, leading to a deficiency in pain management. The facility's policy on pain management, dated December 1, 2024, mandates that pain management services must be provided to residents who require them, including monitoring the effectiveness of medication. However, a review of the medical records for a resident with multiple diagnoses, including Hidradenitis Suppurativa, Diabetes, End Stage Renal Failure, Pain, and Cellulitis, revealed that the resident did not have a documented pain level after the administration of pain medications. The resident, who was cognitively intact with a BIMS score of 15, confirmed that staff did not reassess her pain level after administering pain medication. Interviews with the facility's Nurse Practitioner and the Director of Nursing confirmed that the procedure for pain medication administration includes assessing the resident's pain level before and after administering pain medication, with documentation of the results. Despite receiving pain medication on a routine and as-needed basis, the facility failed to ensure the resident's pain was reassessed for the effectiveness of the pain medication, as required by their policy. This oversight was identified during a survey, highlighting a deficiency in the facility's pain management practices.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications in one of its medication storage areas, specifically the Medication Room. The facility's policy, dated December 1, 2024, mandates that medications be stored in a manner that ensures proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. It specifies that drugs for external use should be stored separately from internal and injectable medications, and medications to be administered by mouth should be stored separately from other formulations. However, during an observation on January 7, 2025, it was found that four tubes of glucose gel, an oral medication, were stored together with hydrocortisone cream and triple antibiotic ointment, both external medications, in a plastic container without a divider. Additionally, the observation revealed that nasal decongestant spray was stored with ear wax removal solution and eye drops in a plastic container without a divider. Interviews with the Licensed Practical Nurse, Assistant Director of Nursing, and Director of Nursing confirmed that these storage practices were not in compliance with the facility's policy. The glucose gel should have been stored separately from the external medications, and the nasal spray should have been stored separately from the ear and eye drops, each with appropriate dividers to ensure proper segregation.
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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