Beech Tree Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Jellico, Tennessee.
- Location
- 240 Hospital Lane, Jellico, Tennessee 37762
- CMS Provider Number
- 445292
- Inspections on file
- 22
- Latest survey
- July 30, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Beech Tree Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to protect residents from abuse and did not identify resident-to-resident altercations as abuse, affecting several residents with cognitive impairments. A resident with severe cognitive impairment wandered into other residents' rooms without interventions, resulting in injuries from an altercation with another aggressive resident. Despite the altercation, no new interventions were implemented, and staff were observed not redirecting the wandering resident. Another resident with a history of aggression was involved in multiple incidents, yet her care plan did not address her behavior. The facility's policies on abuse prevention and intervention were not effectively implemented, leading to a situation of Immediate Jeopardy.
The facility failed to report and investigate incidents of abuse and injuries of unknown origin for several residents, leading to a deficiency in compliance with regulatory requirements. A resident sustained a left femur fracture with an undetermined cause, and no thorough investigation was conducted. Additionally, the facility failed to report and investigate resident-to-resident altercations involving cognitively impaired residents, resulting in injuries. The facility's policies on abuse and unusual occurrences were not followed, and the incidents were not reported to state agencies, local law enforcement, or APS. This placed the residents in Immediate Jeopardy, leading to a citation for substandard quality of care.
The facility failed to investigate an injury of unknown origin and multiple resident-to-resident altercations, which were potential indicators of abuse. A resident with severe cognitive impairment sustained a left femur fracture without a thorough investigation or incident report. Additionally, altercations between residents resulted in injuries, but the facility's investigations were incomplete, lacking necessary documentation and adherence to policies. The failure to investigate these incidents placed residents at risk and resulted in a citation for Immediate Jeopardy.
The facility failed to develop and implement comprehensive person-centered care plans for residents, leading to multiple resident-to-resident altercations and injuries. Residents with aggressive behaviors and cognitive impairments were not provided with appropriate interventions, and care plans were not updated after incidents. The lack of accountability in care planning contributed to immediate jeopardy for the residents involved.
The facility's administration failed to provide effective oversight, leading to deficiencies in abuse prevention and reporting. Incidents involving resident-to-resident altercations and injuries of unknown origin were not properly investigated or reported, placing residents in immediate jeopardy. The administration did not follow the facility's abuse policy, often dismissing incidents due to residents' cognitive impairments, and failed to maintain an effective QAPI program.
The facility's Governing Body failed to provide effective oversight, leading to unreported and uninvestigated resident-to-resident altercations and injuries of unknown origin. A resident with severe cognitive impairment sustained a fracture that was not properly addressed, and another resident with dementia was injured in an altercation. The facility's QAPI program was ineffective, and the Administrator admitted to not reviewing incident reports adequately.
The facility's QAPI program failed to identify and address quality deficiencies related to injuries of unknown origin and abuse for several residents. The program did not conduct thorough investigations or develop person-centered interventions, resulting in an Immediate Jeopardy situation. Incidents involving injuries and resident-to-resident altercations were not reported or investigated properly, and the facility's policies on injury and abuse prevention were not effectively implemented.
The facility failed to provide quarterly financial statements for five residents with personal fund accounts, as required by their policy. The Business Office Manager was unaware that the facility could print and send the statements after the company managing the accounts stopped sending them nearly a year ago. This resulted in residents and their representatives not receiving the required statements.
The facility failed to post accurate daily nurse staffing information for 7 out of 31 days reviewed. The staffing information displayed was outdated, and inconsistencies were found between scheduled and actual staff on several days. The Scheduler confirmed these discrepancies and acknowledged the failure to update the postings.
The facility failed to accurately complete MDS assessments for four residents, missing critical diagnoses and behaviors. A resident with a femur fracture and another with anxiety were not properly documented, while two others with behavioral issues and hallucinations were also inaccurately assessed. These deficiencies indicate a lack of thorough review and communication among staff.
The facility failed to offer hand hygiene assistance to five residents before meals, as observed in dining areas and resident units. Staff members, including an LPN and several CNAs, did not comply with the facility's hand hygiene policy, which requires assistance before meals to prevent infection. The residents involved had various medical conditions and cognitive impairments, and the Director of Nursing confirmed the expectation for hand hygiene assistance.
The facility failed to update the PASRR for two residents after new diagnoses of Major Depressive Disorder were identified. One resident was initially admitted with various mental health conditions, and a new diagnosis of MDD was added later, which was not updated in the PASRR. Similarly, another resident had a new MDD diagnosis that was not reflected in a new PASRR submission. The DON confirmed that the PASRRs should have been resubmitted to include these new diagnoses.
A resident with Alzheimer's and a self-care deficit was observed with dirty fingernails over several days, despite the facility's policy requiring routine nail cleaning during ADL care. The resident expressed a desire for clean nails, and staff confirmed the oversight, acknowledging the expectation to maintain nail hygiene.
A resident with severe cognitive impairment and mobility issues was lowered to the floor during a transfer, resulting in a left femur fracture. Despite the resident's complaints of pain and the diagnosis, the facility failed to conduct a formal investigation or report the incident as an injury of unknown origin. Staff interviews were the only means of determining the cause, and the facility did not follow its policies for fall investigation and reporting.
A facility failed to develop a dementia care plan for a resident diagnosed with dementia, despite the resident being prescribed Aricept for the condition. Observations showed no behavioral concerns, but interviews confirmed the absence of a care plan with person-centered interventions, as required by facility policy.
A facility failed to ensure a physician or NP acted on a pharmacist's recommendation to discontinue Oxybutynin for a resident over 65, due to potential risks. The pharmacist's recommendation was not acknowledged, and no rationale for rejection was documented. The DON and NP confirmed the recommendation was missed in the process.
The facility reported a medication error rate of 7.69%, exceeding the acceptable threshold of 5%. Two residents were affected: one received Albuterol Sulfate incorrectly due to an LPN's failure to follow proper inhalation instructions and timing, while another received Potassium Chloride an hour late due to scheduling issues. The DON was aware of these issues.
Failure to Protect Residents from Abuse and Identify Altercations
Penalty
Summary
The facility failed to protect residents from abuse and did not identify resident-to-resident altercations as abuse, affecting six residents with cognitive impairments. Resident #91, with severe cognitive impairment, wandered into other residents' rooms without interventions to protect her. She sustained injuries from an altercation with Resident #40, who also had severe cognitive impairment and a history of aggressive behaviors. Despite the altercation resulting in scratches on Resident #91's face, no new interventions were implemented to prevent further incidents. Staff were observed not redirecting Resident #91 or offering meaningful activities, and the care plan lacked specific interventions for her wandering behavior. Resident #40, admitted with a history of aggressive behavior, was involved in multiple incidents of aggression, including the altercation with Resident #91. Despite her history and recent aggressive episodes, her care plan did not address her aggressive behavior, and staff were not adequately informed or prepared to manage her actions. The facility's policies on abuse prevention and intervention were not effectively implemented, as evidenced by the lack of appropriate care planning and staff training to handle aggressive residents. Additionally, Residents #24 and #73 were involved in an altercation resulting in injuries, yet their care plans were not updated to reflect the incident. The facility's failure to recognize and address these altercations as abuse, coupled with inadequate interventions and care planning, placed all residents at risk. The facility's policies on abuse prevention and reporting were not followed, leading to a situation of Immediate Jeopardy, which required immediate correction to ensure resident safety.
Failure to Report and Investigate Abuse and Injuries
Penalty
Summary
The facility failed to report and investigate incidents of abuse and injuries of unknown origin for several residents, leading to a deficiency in compliance with regulatory requirements. Resident #39, who was severely cognitively impaired and non-ambulatory, sustained a left femur fracture with an undetermined cause. Despite the resident's complaints of pain and swelling in the right leg, the facility's documentation did not mention any issues with the left leg, and no thorough investigation was conducted to determine the cause of the fracture. The Director of Nursing (DON) and the Administrator did not consider the incident reportable, and no formal investigation or root cause analysis was performed. Additionally, the facility failed to report and investigate resident-to-resident altercations involving Residents #24, #73, #46, #44, #91, and #40. These residents, who were all cognitively impaired, were involved in physical altercations that resulted in injuries. The facility's staff witnessed these incidents but did not report them to the appropriate authorities, citing the residents' cognitive impairments as a reason for not considering the incidents as abuse. The facility's policies on abuse and unusual occurrences were not followed, and the incidents were not reported to state agencies, local law enforcement, or Adult Protective Services (APS). The facility's failure to identify and investigate potential abuse and injuries of unknown origin placed the residents in Immediate Jeopardy, a situation that could cause serious harm or death. The facility's policies required reporting of such incidents within specific timeframes, but these were not adhered to. The Administrator, who was also the facility's abuse coordinator, and the DON did not ensure that the facility's policies and federal regulations were followed, leading to a citation for Immediate Jeopardy at F-609 with a scope and severity of K, indicating substandard quality of care.
Failure to Investigate Injuries and Altercations
Penalty
Summary
The facility failed to investigate an injury of unknown origin and multiple resident-to-resident altercations, which were potential indicators of abuse, for several residents. Resident #39, who was severely cognitively impaired and non-ambulatory, sustained a left femur fracture with an undetermined cause. Despite the resident's complaints of pain and swelling in the right leg, the facility's documentation did not reflect any investigation into the left leg injury, nor was an incident report completed. The Director of Nursing (DON) and the Administrator did not conduct a formal investigation or root cause analysis, and the incident was not reported as an injury of unknown origin. Additionally, the facility did not adequately investigate three separate resident-to-resident altercations. In one incident, two severely cognitively impaired residents, #73 and #24, were involved in a physical altercation, resulting in injuries to both. The facility's investigation was incomplete, lacking witness statements and resident interviews, and the care plans for the residents were not updated to reflect the altercation. In another incident, Resident #46 sustained injuries after an altercation with Resident #44, but there was no documentation of an incident report or investigation. The DON was informed of the incident but did not consider it abuse due to the residents' cognitive impairments. The facility's policies on abuse prohibition and investigation were not followed, as evidenced by the lack of thorough investigations and documentation for the incidents. The Administrator, who was responsible for abuse investigations, confirmed that the facility did not adhere to its policies or federal regulations. The failure to investigate these incidents placed the residents at risk and resulted in a citation for Immediate Jeopardy, indicating a situation that could cause serious harm to residents.
Removal Plan
- The facility provided an acceptable Removal Plan for F-610.
- The corrective actions were validated on site by the surveyor for F-610.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to multiple incidents of resident-to-resident altercations and injuries. Residents with histories of aggressive behaviors and cognitive impairments, such as dementia, were not provided with appropriate interventions to manage their behaviors. For instance, one resident with a history of aggressive behavior was involved in an altercation with another resident, resulting in scratches and injuries. Despite the incident, no new interventions were added to the care plans to prevent further occurrences. Additionally, the facility did not address the wandering behaviors of a resident with severe cognitive impairment, which led to altercations with other residents. The care plans lacked specific interventions to manage the resident's wandering and interactions with others, contributing to the potential for further incidents. The facility's failure to update care plans after incidents or to include person-centered activities and interventions for residents with behavioral issues was a significant deficiency. The facility's care planning process was inadequate, as evidenced by the lack of updates and revisions to care plans following incidents. The responsibility for creating and revising care plans was unclear, with the MDS Coordinator position vacant and no designated staff member taking charge of care plan updates. This lack of accountability and oversight in care planning contributed to the facility's inability to address and manage residents' needs effectively, leading to immediate jeopardy for the residents involved.
Deficiency in Abuse Prevention and Reporting
Penalty
Summary
The facility's administration failed to provide effective leadership and oversight, resulting in a deficiency related to abuse prevention and reporting. The administration did not ensure that systems were in place to protect residents from abuse, investigate allegations, or report incidents to the appropriate authorities. This failure placed several residents in immediate jeopardy, as the facility did not recognize resident-to-resident altercations and injuries of unknown origin as potential abuse. The administration also failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program, which is crucial for identifying and addressing such issues. Several incidents highlighted these deficiencies. Resident #39, with severe cognitive impairment, was found to have a left femur fracture, but the facility did not conduct a thorough investigation or report the injury as an injury of unknown origin. Similarly, altercations between residents, such as those involving Residents #91 and #40, and Residents #24 and #73, were not properly investigated or reported. The facility's staff, including the Director of Nursing (DON) and the Administrator, did not follow the facility's abuse policy, often dismissing incidents due to the residents' cognitive impairments. The facility's administration, including the Administrator and the DON, failed to recognize the seriousness of these incidents and did not conduct root cause analyses or report them as required. The facility's policies on abuse prevention and investigation were not followed, and the administration did not ensure that staff were adequately trained to identify and report abuse. This lack of compliance with federal, state, and local regulations resulted in a citation for immediate jeopardy, highlighting the administration's failure to protect residents and maintain an effective QAPI program.
Removal Plan
- The Administrator and DON received education on how to identify, investigate, and report future allegations of abuse and injury of unknown origin.
- Staff will receive education on how to identify abuse. Staff education will be conducted by the Risk Manager and the DON.
- The DON will be responsible for monitoring compliance.
- The Director of Reimbursement and Clinical Services will provide daily oversight of the facility.
- The Governing Body, facility leadership and members of the operations, compliance and QAPI corporate staff will determine if additional oversight is needed.
- Ad-Hoc QAPI meetings will be held with representatives of the Governing Body, members of the operation, compliance and QAPI corporate staff to review results of audits, rounds, patterns/trends identified through SOC meetings, and other compliance monitoring activities.
- The facility will continue to hold SEC calls to review and discuss events and incidents.
- QAPI meetings will be attended by the QAPI team and members of the Governing Body. Based on patterns/trends identified, an educational plan will be created for the facility.
Failure to Identify and Report Abuse in LTC Facility
Penalty
Summary
The facility's Governing Body failed to provide effective leadership and oversight, resulting in a deficiency related to residents' rights to be free from abuse. The facility did not identify, investigate, or report resident-to-resident altercations and injuries of unknown origin as potential abuse cases. This failure affected four residents, including one with severe cognitive impairment and a history of maltreatment, who sustained a fracture that was not properly investigated or reported. Another resident with dementia and a history of wandering was involved in an altercation with another resident, resulting in injuries that were not reported or investigated as abuse. The facility's policies on abuse prevention and QAPI were not effectively implemented. The Administrator and DON did not complete thorough investigations or root cause analyses for incidents involving resident altercations and injuries of unknown origin. The facility's QAPI program was not effective in identifying and resolving issues related to abuse investigations and reporting. The Administrator admitted that incident reports were not being reviewed as they should be, and the facility's QAPI meetings did not address the incidents involving the affected residents. Interviews with facility staff, including the Administrator and the VP of Regulatory Compliance and QAPI Program Consultant, revealed a lack of recognition of abuse allegations and a failure to follow established policies. The facility did not conduct thorough investigations or report incidents to local and state authorities. The Administrator acknowledged that the facility's QAPI program had room for improvement, but believed it was effective despite the identified deficiencies.
Removal Plan
- The Administrator and DON received education on how to identify, investigate, and report future allegations of abuse and injuries of unknown origin.
- Staff will receive education on how to identify abuse, conducted by the Risk Manager and the DON.
- The DON will be responsible for monitoring compliance.
- The Director of Reimbursement and Clinical Services will provide daily oversight of the facility.
- The Governing Body, facility leadership, and members of the operations, compliance, and QAPI corporate staff will determine if additional oversight is needed.
- Ad-Hoc QAPI meetings will be held with representatives of the Governing Body, members of the operation, compliance, and QAPI corporate staff to review results of audits, rounds, patterns/trends identified through SOC meetings, and other compliance monitoring activities.
- The facility will continue to hold SEC calls to review and discuss events and incidents.
- QAPI meetings will be attended by the QAPI team and members of the Governing Body. Based on patterns/trends identified, an educational plan will be created for the facility.
QAPI Program Failure in Identifying and Addressing Abuse and Injuries
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) program failed to identify and address quality deficiencies related to injuries of unknown origin and abuse for four residents. The program did not conduct thorough investigations, perform root cause analyses, or develop person-centered interventions. This failure resulted in an Immediate Jeopardy situation, indicating that the noncompliance had caused or was likely to cause serious harm to residents. The facility's policies on injury of unknown source and abuse prevention were not effectively implemented, leading to unreported and uninvestigated incidents. Resident #39 experienced a fracture that was not identified as an injury of unknown origin, and no incident report or thorough investigation was conducted. The resident had a witnessed fall, but the connection to the fracture was not made until much later. Similarly, resident-to-resident altercations involving residents #91, #40, #24, #73, #46, and #44 were not recognized as abuse due to the residents' cognitive impairments. These incidents were not reported to local and state authorities, and the facility failed to follow its abuse policy. The facility's QAPI meetings did not address these incidents, and the Administrator admitted that incident reports were not being reviewed as they should be. The QAPI program was deemed ineffective, with weaknesses in identifying and addressing abuse allegations. The facility's failure to maintain an effective QAPI program and to identify and report serious outcomes related to abuse had the potential to impact all residents.
Removal Plan
- The Administrator and DON received education on how to identify, investigate, and report future allegations of abuse and injury of unknown origin.
- The education included review of the Administrator and DON's responsibility to operate/manage the facility efficiently and effectively to ensure each resident maintains the highest practicable physical, mental, and psychosocial well-being.
- A review of the tools to be used for future allegations and interviews with the Administrator and DON confirmed they acknowledged their roles and responsibilities.
- Staff will receive education on how to identify abuse. Staff education will be conducted by the Risk Manager and the DON. The DON will be responsible for monitoring compliance.
- The Director of Reimbursement and Clinical Services will provide daily oversight of the facility. The Governing Body, facility leadership and members of the operations, compliance and QAPI corporate staff will determine if additional oversight is needed.
- Ad-Hoc QAPI meetings will be held with representatives of the Governing Body, members of the operation, compliance and QAPI corporate staff to review results of audits, rounds, patterns/trends identified through SOC (risk) meetings, and other compliance monitoring activities.
- The facility will continue to hold SEC calls to review and discuss events and incidents.
- QAPI meetings will be attended by the QAPI team and members of the Governing Body. Based on patterns/trends identified, an educational plan will be created for the facility.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to provide quarterly financial statements for five residents with personal fund accounts, as required by their policy. The policy states that residents have the right to manage their financial affairs and should receive individual financial records through quarterly statements. However, the facility did not provide these statements to Residents #8, #27, #28, #34, and #78, all of whom had personal fund accounts managed by the facility. Interviews with the residents and their responsible parties confirmed that they did not receive the required quarterly statements. The Business Office Manager (BOM) acknowledged responsibility for managing resident trust accounts and stated that the company previously mailed the quarterly statements to the facility, which were then sent to the residents. However, the company stopped sending these statements nearly a year ago, and the BOM was unaware that the facility had access to print and send the statements themselves. As a result, the quarterly resident trust account statements had not been sent to the residents or their representatives for almost a year, leading to the deficiency.
Inaccurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate daily nurse staffing information for 7 out of 31 days reviewed. The facility's policy, titled Staffing Posting Guidelines, requires the posting of current staffing information, including the total number of hours worked by RNs, LPNs, and CNAs, in the lobby or entrance area. However, during an observation on April 1, 2024, the staffing information displayed was outdated, showing the schedule for March 28, 2024, instead of the current date. This discrepancy was confirmed by the Scheduler, who acknowledged that the correct staffing information had not been posted since March 28, 2024. Further review of the daily nurse staffing sheets compared to actual time punches from March 16, 2024, to March 29, 2024, revealed inconsistencies on six days. For instance, on March 17, 2024, six CNAs were scheduled, but only four actually worked. Similar discrepancies were noted on other dates, with fewer CNAs or LPNs working than scheduled. The Scheduler confirmed these inconsistencies and stated that it was her responsibility to post the daily staffing information. She also mentioned that any changes or call-ins were supposed to be manually updated by a floor nurse, which evidently did not occur, leading to inaccurate staffing postings.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in capturing their current health status. Resident #39, who was admitted with diagnoses including Dementia and a left femur fracture, had an MDS assessment that did not document the fracture, despite confirmation from the Regional Remote MDS Coordinator that the assessment was inaccurate. Similarly, Resident #78, diagnosed with Anxiety and receiving Buspirone for treatment, had MDS assessments that failed to include the anxiety diagnosis, as confirmed by the Director of Nursing. Resident #20, with diagnoses including Major Depressive Disorder and Anxiety Disorder, exhibited behaviors such as agitation and turning over furniture, which were not captured in the MDS assessment. The Social Service Director acknowledged the oversight, stating that the behaviors should have been documented. Additionally, Resident #46, who experienced hallucinations involving his deceased wife, had an MDS assessment that did not reflect these behaviors. The Director of Nursing confirmed that the hallucinations and delusions should have been included in the assessment. These deficiencies highlight a pattern of incomplete and inaccurate MDS assessments, which are crucial for generating an accurate picture of residents' health status. The failure to document significant diagnoses and behaviors in the MDS assessments indicates a lack of thorough review and communication among staff, as well as a failure to adhere to the guidelines outlined in the Resident Assessment Instrument Manual 3.0.
Failure to Provide Hand Hygiene Assistance Before Meals
Penalty
Summary
The facility failed to offer hand hygiene assistance to five residents before meals, as observed in one of two dining areas and two of three resident units during meal tray distribution. The facility's policy on hand hygiene, dated June 2023, mandates that staff assist residents with hand hygiene before meals to prevent the spread of infection. However, during observations on April 1, 2024, staff members, including LPN #9 and CNAs #9, #10, #11, and #12, did not offer hand hygiene assistance to residents before serving their meals. This was confirmed through interviews with the staff, who acknowledged their failure to comply with the facility's hand hygiene policy. The residents involved had various medical conditions and cognitive impairments. Resident #78, with dementia and mild neurocognitive disorder, was not offered hand hygiene assistance by LPN #9. Resident #203, with severe cognitive impairment, was similarly neglected by CNA #9. Resident #50, with Alzheimer's disease, and Resident #54, with severe cognitive impairment, were not assisted by CNAs #10 and #12, respectively. Resident #79, with moderate cognitive impairment, was also not offered hand hygiene by CNA #11. The Director of Nursing confirmed that it was expected for residents to be offered hand hygiene assistance prior to meals.
Failure to Update PASRR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to resubmit a Pre-Admission Screening and Resident Review (PASRR) in a timely manner after new mental health diagnoses were identified for two residents. Resident #27 was initially admitted with diagnoses including Dementia, Psychosis, Depression, PTSD, Agoraphobia, and Panic Disorder. A PASRR Level I Screen dated December 7, 2021, indicated no Level II condition, and the outcome was negative. However, a new diagnosis of Major Depressive Disorder (MDD) was added on September 19, 2022, which was not updated in the PASRR. The Director of Nursing (DON) confirmed that the PASRR should have been resubmitted to include the new diagnosis, as MDD is distinct from mild or situational depression. Similarly, Resident #78 was admitted with diagnoses including Dementia, Mild Neurocognitive Disorder, PTSD, Nightmare Disorder, Anxiety, and Depression. A Level I PASRR dated March 16, 2023, also showed a negative outcome. However, a new diagnosis of MDD was added on April 17, 2023, which was not reflected in a new PASRR submission. The DON acknowledged responsibility for PASRRs and confirmed that a new PASRR should have been submitted following the new diagnosis. These oversights indicate a failure to adhere to the facility's policy of promptly referring residents with new or serious mental disorders for a Level II resident review.
Failure to Provide Nail Care During ADL
Penalty
Summary
The facility failed to provide adequate nail care during Activities of Daily Living (ADL) for a resident diagnosed with Alzheimer's Disease and Cerebral Infarction. The facility's policy on ADL care, which includes routine cleaning and inspection of nails, was not adhered to for this resident. The resident, who was cognitively intact and required extensive assistance with personal hygiene due to a self-care performance deficit related to weakness and a left below the knee amputation, was observed multiple times with visibly dirty fingernails. Observations conducted over several days revealed that the resident's fingernails remained dirty, despite the facility's policy and the resident's expressed desire to have them cleaned. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed the oversight. The Director of Nursing acknowledged that the nursing staff was expected to maintain residents' nail hygiene during ADL care or showers, as per the facility's policy.
Failure to Investigate and Report Resident Fall
Penalty
Summary
The facility failed to identify and complete a fall investigation for a resident who was involved in an incident during a transfer. The resident, who had severe cognitive impairment and required substantial assistance with mobility, was reportedly lowered to the floor by two CNAs during a transfer to a shower chair. Despite the resident's complaints of pain and subsequent diagnosis of a left femur fracture, no incident report or investigation was conducted to determine the root cause of the injury. Interviews with staff revealed that the incident was not reported as a fall, and no formal investigation or root cause analysis was conducted. The CNAs involved in the transfer did not complete an incident report, and the LPN on duty at the time did not perceive the event as a fall, as the resident was only lowered to the floor. The DON and Administrator were aware of the fracture after the resident was sent to the hospital, but they did not consider the incident as reportable or conduct a thorough investigation. The facility's policies for identifying, investigating, and reporting falls or injuries of unknown origin were not followed. The Administrator, who was also the Abuse Coordinator, relied solely on staff interviews to determine the cause of the injury. The lack of a formal investigation and failure to report the incident as an injury of unknown origin contributed to the deficiency in the facility's handling of the resident's fall and subsequent injury.
Failure to Develop Dementia Care Plan for Resident
Penalty
Summary
The facility failed to develop a dementia care plan for a resident diagnosed with dementia, as required by their policy. The resident, who was admitted with diagnoses including dementia, lack of coordination, and bipolar disorder, had an active diagnosis of non-Alzheimer's dementia. Despite this, the comprehensive care plan did not include a dementia care plan. The resident was prescribed Aricept, a medication for dementia, indicating the need for a care plan addressing this condition. Observations over several days showed no concerns related to the resident's behaviors or dementia diagnosis. Interviews with the Director of Nursing and the Regional Remote MDS Coordinator confirmed the absence of a dementia care plan, acknowledging that the care plan should have included person-centered interventions for the resident's dementia. Staff interviews indicated awareness of non-pharmacological approaches for behaviors, but the deficiency remained in the lack of a formalized care plan.
Failure to Act on Pharmacist's Medication Recommendation
Penalty
Summary
The facility failed to ensure that a physician or nurse practitioner acted upon a recommendation from the consultant pharmacist regarding a potentially inappropriate medication for a resident. The facility's policy requires a licensed pharmacist to perform a monthly drug regimen review and communicate any irregularities to the attending physician, Medical Director, and Director of Nursing. In this case, the consultant pharmacist identified Oxybutynin as potentially inappropriate for a resident over 65 due to increased sedation and anticholinergic effects, and recommended discontinuation. However, this recommendation was not acknowledged or acted upon by the physician or nurse practitioner. The resident involved had a history of osteoarthritis, dementia, psychosis, chronic kidney disease, renal insufficiency, and restless leg syndrome. Despite the pharmacist's recommendation, the medication regimen was not adjusted, and no rationale for rejecting the recommendation was documented. Interviews with the Director of Nursing and the nurse practitioner revealed that the recommendation was not addressed, as it was missed in the process of being placed in the nurse practitioner's inbox. The nurse practitioner stated she did not recall seeing the recommendation and would not have changed the medication if she had seen it.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate. This deficiency involved two residents. The first resident, with diagnoses including Diabetes Mellitus Type 2 and Acute Bronchitis, was administered Albuterol Sulfate incorrectly by an LPN. The LPN did not instruct the resident to inhale and exhale properly before administering the medication and failed to wait the required one minute between puffs, as per the manufacturer's guidelines and physician orders. The LPN acknowledged the mistake during an interview, and the Director of Nursing confirmed the error. The second resident, diagnosed with conditions such as Metabolic Encephalopathy and Heart Failure, received Potassium Chloride an hour late. The LPN responsible for administering the medication stated that she started her shift at 8:00 AM, which led to the delay in administering the 7:00 AM medication. The DON was aware of this scheduling issue and expected the unit manager to cover the administration of medications until the LPN arrived. The DON confirmed that the medication was administered late, contributing to the facility's medication error rate.
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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