Church Hill Post-acute And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Church Hill, Tennessee.
- Location
- 701 West Main Blvd, Church Hill, Tennessee 37642
- CMS Provider Number
- 445237
- Inspections on file
- 23
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Church Hill Post-acute And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not comply with its own policy requiring a full-time social worker and went extended periods without a qualified social worker on staff. Over multiple months within a 9‑month review period, no qualified social worker was employed, and an unqualified staff member who originally worked as a concierge was informally assigned to handle social work responsibilities despite lacking a social work degree or training. The Administrator confirmed these gaps in qualified social work coverage.
A resident with multiple complex medical conditions did not have the required interdisciplinary team (IDT) members, such as a nurse or physician, present at care plan meetings. Documentation and staff interviews confirmed that only the Social Services Director, Dietary Manager, and the resident or representative attended, contrary to facility policy requiring broader IDT participation.
A resident with multiple health conditions was mistakenly given the wrong tube feeding formula, Osmolite 1.2 CAL, instead of the prescribed Glucerna 1.5 CAL. The error was discovered by an LPN the next morning, and the correct formula was administered immediately. The resident showed no signs of distress, and the incident was reported to the DON and Medical Director.
The facility failed to ensure staff understood Enhanced Barrier Precautions (EBP) and PPE use, affecting residents with COVID-19 and other infections. Observations showed staff entering rooms without proper PPE or hand hygiene. Interviews revealed a lack of training and understanding of EBP, with outdated policies contributing to the issue.
The facility failed to follow CDC guidelines for COVID-19 prevention and control, leading to two outbreaks affecting residents and staff. The administration did not ensure staff competency in Enhanced Barrier Precautions and PPE usage, allowed COVID-19 positive employees to work with non-positive residents, and failed to quarantine individuals as required. The QAPI program did not address these deficiencies, and the Medical Director's concerns about infection control practices were not implemented.
The facility's Governing Body failed to ensure compliance with CDC guidelines for COVID-19 prevention, leading to inadequate staff competency in infection control practices and improper use of PPE. The facility experienced two COVID-19 outbreaks, with positive employees returning to work prematurely, increasing infection risk. The QAPI program was ineffective in addressing these issues, and discrepancies in meeting records raised concerns about oversight. Interviews revealed poor communication between the Administrator and the Governing Body, with no formal reporting process in place.
The facility's QAPI program failed to address infection control deficiencies, allowing COVID-19 positive employees to work and exposing residents to infection. Two outbreaks occurred, with 28 residents and 15 employees testing positive initially, and 10 residents and 5 employees in a subsequent outbreak. The facility did not follow CDC guidelines for isolation, failed to ensure competent staff, and did not comply with physician's orders, resulting in Immediate Jeopardy for all residents.
The facility failed to follow CDC guidelines for COVID-19 management, resulting in two outbreaks affecting residents and staff. The facility did not properly identify and track infections, enforce PPE use, or conduct necessary testing and quarantine measures. This led to an Immediate Jeopardy situation, indicating a serious risk of harm.
The facility failed to monitor vital signs every four hours for residents with active COVID-19 infections, as per physician orders, and improperly administered medication to a resident at high risk for aspiration. These deficiencies led to an Immediate Jeopardy situation, indicating a potential for serious harm to residents.
The facility failed to maintain a clean and homelike environment, with observations revealing stained carpets and disrepair in resident rooms, including broken furniture and exposed drywall. Staff confirmed awareness of these issues, which had been pending repair since 2022.
The facility failed to discard expired food items in the kitchen, affecting all 99 residents. An observation revealed expired grits, bologna, and allspice available for use, along with improperly sealed black pepper. The CDM confirmed these items were expired and not discarded.
The facility failed to develop and implement baseline care plans for residents admitted with active COVID-19 infections, as required by their policy. Despite physician orders for isolation precautions and regular monitoring, the care plans did not reflect these needs, leaving staff unaware of necessary PPE requirements. This oversight was confirmed by the MDS/Care Plan Coordinator, highlighting a significant lapse in policy adherence.
The facility failed to timely revise care plans for residents with COVID-19, falls, and code status changes. Care plans for ten residents were not updated to include COVID-19 isolation requirements, and a resident's fall risk was not addressed with new interventions. Additionally, a resident's code status change to DNR was not reflected in their care plan.
The facility failed to properly store medications in two medication carts. A resident's Lorazepam liquid was stored at room temperature instead of refrigerated, risking reduced effectiveness. Additionally, two house stock medications for constipation were found opened and undated. The facility's policy requires proper storage conditions, including refrigeration for certain medications.
A resident with multiple health conditions was mistakenly given the wrong tube feeding formula for about 10 hours. The error was discovered by an LPN, and the correct formula was administered immediately. The resident showed no signs of distress, and the incident was reported to the DON and Medical Director.
A resident with moderate cognitive impairment and an indwelling urinary catheter had their drainage bag left uncovered and visible to the public, contrary to their care plan. This oversight was confirmed by a registered nurse, highlighting a failure to maintain the resident's dignity.
The facility failed to protect residents' health information on D-Wing and C-Wing. On D-Wing, an RN left a computer screen unlocked on a medication cart, exposing residents' health information. On C-Wing, an LPN left a resident roster with sensitive information visible on a medication cart. Both staff members confirmed the lapses in maintaining confidentiality.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in care. A resident with a gallbladder drain did not have this included in their care plan, while another resident with COVID-19 lacked related interventions. Additionally, a resident requiring one-on-one supervision for sexual behaviors was left unsupervised, and a resident needing meal assistance did not receive it. These oversights were confirmed by staff and care plan reviews.
The facility failed to maintain and store oxygen equipment in a clean and sanitary condition for two residents. A resident with Dementia and other conditions had a nebulizer mask uncovered on the nightstand, confirmed by an LPN. Another resident with COPD and other diagnoses had multiple nebulizer masks, some out of date and one with a cloudy substance, not stored properly. An LPN confirmed the unsanitary conditions and was unsure about the cleaning schedule.
A facility failed to obtain a physician's order for bed rail use for a resident with conditions including Epilepsy and Cerebral Palsy. The resident's care plan included padded bed rails for protection, but observations and staff interviews confirmed the rails were in use before obtaining the necessary order, contrary to facility policy.
The facility failed to maintain complete records of pharmacy reviews and provider responses for two residents. A resident with multiple diagnoses, including Rheumatoid Arthritis and Depression, had medication irregularities noted by the pharmacist, but the medical record lacked documentation of these irregularities and provider responses. Another resident with Delusional Disorder and Dementia also had similar issues. Staff confirmed the absence of necessary documentation, indicating a lapse in maintaining accurate medication records.
The facility's assessment failed to accurately reflect the needs of two residents, one identifying as transgender and another with a language barrier, as it did not account for their specific cultural and communication preferences.
The facility failed to document COVID-19 test results accurately for several residents, leading to inconsistencies in medical records. Additionally, a urinalysis was not obtained timely for a resident with altered mental status, and a transcription error resulted in a medication administration record not reflecting the correct dosage for over a year. These deficiencies highlight lapses in documentation and communication within the facility.
A facility failed to report an alleged abuse incident to the State Survey agency as required by policy. An EMT reported potential sexual abuse of a resident, but the facility's investigation found no evidence, deeming it malicious gossip. The resident, who was cognitively intact, had been evaluated in the ER for self-harm thoughts. The facility did not report the allegation, leading to a deficiency.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker as required by its own policy and federal regulations for a facility with more than 120 beds. The facility’s undated Social Services guidelines stated that a social worker would be employed on a full-time basis, yet a facility document signed by the Administrator on 2/12/2026 showed that from 5/9/2025 to 5/27/2025, 6/10/2025 to 8/11/2025, 10/8/2025 to 11/26/2025, and from 1/5/2026 to 2/12/2026, the facility did not employ a qualified social worker, totaling approximately 167 days (5.5 months) out of 9 months reviewed. During an interview, the individual currently functioning in the social worker role stated they began employment in October as a concierge and served in that role until early January, after which they were acting as the social worker despite having no social work degree or training and only “helping out with the social worker stuff” until a social worker could be hired. In a separate interview, the Administrator confirmed the periods during which the facility did not have a qualified social worker employed.
Failure to Ensure Required IDT Attendance at Care Plan Meetings
Penalty
Summary
The facility failed to ensure that the minimum required interdisciplinary team (IDT) members attended care plan meetings for a resident who was admitted and later readmitted with multiple complex diagnoses, including hepatic encephalopathy, alcoholic cirrhosis with ascites, dependence on renal dialysis, and esophageal varices. According to facility policy, the IDT for care planning should include, at a minimum, the attending physician, a registered nurse, a nursing assistant, a member of food and nutrition services, the resident or their representative, and other appropriate staff. However, documentation for three separate care plan meetings showed that only the Social Services Director, the Dietary Manager, and the resident or their representative were present, with no nurse, physician, or other required disciplines in attendance. Interviews with the Director of Nursing and the Social Services Director confirmed that the full IDT was not present at these meetings. The Social Services Director stated that only she and the Dietary Manager attended the meetings, and that other required staff were not present due to being occupied with other duties. This failure to include the required disciplines in the care plan meetings was identified through facility documentation review, medical record review, and staff interviews.
Failure to Administer Correct Tube Feeding Formula
Penalty
Summary
The facility failed to administer the correct tube feeding formula as ordered by the physician for a resident who was dependent on tube feeding for nutrition and hydration. The resident, who had a history of stroke, epilepsy, type 2 diabetes, gastrointestinal bleed, dysphagia, and aphasia, was supposed to receive Glucerna 1.5 at 70 milliliters per hour. However, on January 1, 2025, the resident was mistakenly given Osmolite 1.2 CAL instead of the prescribed Glucerna 1.5 CAL. This error was discovered by an LPN the following morning, and the correct formula was administered immediately thereafter. The incident was reported to the Director of Nursing and the Medical Director, who confirmed that the resident did not exhibit any signs of distress or discomfort following the administration of the incorrect formula. The facility's policy on feeding tube guidelines emphasizes the importance of administering enteral nutrition as per the practitioner's orders, which was not adhered to in this case. The Executive Director of Nursing expressed that it was expected for nurses to follow the physician's orders accurately.
Deficiency in Infection Control and PPE Usage
Penalty
Summary
The facility failed to ensure that nursing staff were knowledgeable and fully understood Enhanced Barrier Precautions (EBP) and the appropriate use of Personal Protective Equipment (PPE) for residents with active COVID-19 infections and other infectious organisms. This deficiency was observed across multiple hallways, affecting several residents who required EBP for various conditions, including wounds, ESBL infections, and indwelling urinary devices. The facility's non-compliance placed residents in Immediate Jeopardy, as staff did not adhere to infection control practices, such as wearing gowns and gloves during high-contact activities and performing hand hygiene. Observations revealed that staff, including Patient Care Assistants (PCAs) and Certified Nursing Assistants (CNAs), frequently entered and exited rooms without performing hand hygiene or wearing the required PPE. For instance, a PCA was observed delivering meal trays to multiple residents in EBP rooms without washing hands or wearing gowns and gloves. Similarly, a Paid Feeding Assistant (PFA) entered a droplet isolation room without the appropriate PPE, and a Risk Manager entered a COVID-19 positive resident's room without donning PPE, later accessing clean supplies and re-entering the room. Interviews with staff indicated a lack of understanding and training regarding EBP and PPE requirements. Some staff believed EBP signage was only for CNAs or associated it with the need for barrier cream, rather than infection control measures. The Infection Preventionist (IP) and Assistant Director of Nursing (ADON) acknowledged deficiencies in staff education and infection control practices, with outdated policies and a lack of awareness of current CDC guidelines contributing to the issue. The facility's administration recognized the need for improvement in infection prevention and control practices, as well as competent staffing.
Failure to Adhere to CDC Guidelines and Infection Control Practices
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Summary
The facility's administration failed to adhere to current CDC guidelines for preventing and controlling the spread of COVID-19 among residents and staff. This included a lack of competency and knowledge among staff regarding Enhanced Barrier Precautions (EBP) and COVID-19 isolation practices, such as the use of appropriate Personal Protective Equipment (PPE) for potentially contagious residents. The administration also failed to accurately identify residents with an active COVID-19 diagnosis and did not complete COVID-19 testing for staff during outbreaks from August to November 2024. Additionally, COVID-19 positive employees were allowed to provide care for COVID-19 negative residents, and the facility did not quarantine COVID-19 positive individuals for the required time frame as recommended by the CDC. The facility experienced two COVID-19 outbreaks, with the first occurring from August 9, 2024, to October 11, 2024, affecting 28 residents and 15 employees. The second outbreak began on October 19, 2024, and continued, affecting 10 residents and 5 employees. During these outbreaks, the facility allowed 17 out of 20 COVID-19 positive employees to return to work before completing the required isolation period, increasing the risk of spreading the infection. The facility also failed to ensure that nursing staff were knowledgeable about identifying residents on EBP and active COVID-19 residents, and did not implement appropriate PPE usage for isolation rooms. The facility's Quality Assurance and Performance Improvement (QAPI) program failed to identify and address infection control deficiencies, including the unsafe practice of allowing COVID-19 positive employees to care for non-COVID-19 positive residents. The QAPI committee and the Governing Body did not recognize the need to address staff competency related to infection control practices, nor did they implement corrective actions for deficiencies in physician order compliance related to vital sign monitoring and medication administration. The Medical Director expressed concerns about inconsistent PPE usage and infection control practices, which were not addressed by the facility administration.
Inadequate Oversight and Infection Control Failures
Penalty
Summary
The Governing Body of the facility failed to provide adequate oversight to ensure compliance with CDC guidelines for preventing and controlling the spread of COVID-19. This included a lack of oversight in ensuring staff competency in Enhanced Barrier Precautions (EBP) and COVID-19 isolation practices, as well as the use of appropriate Personal Protective Equipment (PPE) for potentially contagious residents. The facility also failed to accurately identify residents with active COVID-19 infections and did not complete COVID-19 testing for staff according to CDC guidelines during outbreaks. Furthermore, COVID-19 positive employees were allowed to provide care to COVID-19 negative residents, increasing the risk of infection spread. The facility's Quality Assurance and Performance Improvement (QAPI) program was ineffective in identifying and addressing systemic failures related to infection control. The QAPI committee and the Governing Body did not recognize the need to address staff competency in infection control practices, nor did they implement corrective actions for deficiencies in following physician orders for vital sign monitoring and medication administration. The facility experienced two COVID-19 outbreaks, with numerous residents and employees testing positive, yet failed to implement effective measures to control the spread of the virus. Interviews with facility staff revealed a lack of communication and formal reporting between the Administrator and the Governing Body. The Administrator was unable to identify Governing Body members and admitted that there was no formal process for reporting facility issues to them. Additionally, discrepancies were found in the QAPI meeting signature logs, with signatures being added after the fact, raising concerns about the accuracy of attendance records. The Governing Body members could not recall specific discussions or actions taken to address COVID-19 infection control issues, indicating a lack of engagement and oversight in critical areas of facility management.
Inadequate Infection Control and QAPI Program Leads to Immediate Jeopardy
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to effectively identify and address quality deficiencies, particularly in infection control practices. The QAPI committee did not develop or implement effective processes or action plans for performance improvement, failing to recognize poor infection control practices and ensure an effective infection control program. This oversight allowed COVID-19 positive employees to work and provide care for vulnerable and COVID-19 negative residents, exposing them to the infection. The facility census was 99, and the failure to implement proper infection control practices resulted in an Immediate Jeopardy situation, impacting all residents. The facility experienced two COVID-19 outbreaks, with 28 residents and 15 employees testing positive during the first outbreak and 10 residents and 5 employees during the second. The facility allowed 17 of the 20 COVID-19 positive employees to return to work before the required isolation time frame recommended by CDC guidance, increasing the likelihood of spreading the infection. Additionally, the facility failed to accurately identify COVID-19 positive residents and those requiring Enhanced Barrier Precautions (EBP), with employees being non-compliant with PPE usage in EBP rooms for 6 of 26 residents. The facility administration failed to ensure competent nursing staff who understood isolation guidelines and implemented appropriate PPE usage. The administration also failed to ensure compliance with physician's orders and professional standards of care, resulting in substandard quality of care. The Governing Body did not provide adequate oversight to address non-compliance related to infection control, isolation guidelines, and PPE usage. Despite the Medical Director voicing concerns about infection control practices, the facility did not implement his recommendations, contributing to the deficiencies.
Failure to Follow CDC Guidelines for COVID-19 Management
Penalty
Summary
The facility failed to adhere to current CDC guidelines for infection prevention and control, specifically in managing COVID-19 outbreaks. The facility did not properly identify and track residents and staff with active COVID-19 infections during two separate outbreaks. This failure resulted in the spread of COVID-19 among 28 residents and 15 employees during the first outbreak, and 10 residents and 5 employees during the second outbreak. The facility also did not ensure that COVID-19 positive residents were quarantined according to CDC guidance, as evidenced by the cases of several residents who were admitted with COVID-19 but not isolated for the recommended duration. Additionally, the facility did not enforce the use of appropriate Personal Protective Equipment (PPE) in COVID-19 isolation rooms. Staff members were observed not wearing the necessary PPE, such as N95 respirators, gowns, gloves, and eye protection, when entering rooms of residents with confirmed COVID-19 infections. This noncompliance with PPE protocols was noted for multiple residents who were supposed to be under Enhanced Barrier Precautions. The facility also failed to conduct facility-wide employee testing and did not adhere to recommended quarantine times during the COVID-19 outbreaks. Several employees who tested positive for COVID-19 were not excluded from work for the required isolation period, increasing the risk of further transmission within the facility. These deficiencies led to an Immediate Jeopardy situation, indicating a serious risk of harm to residents.
Failure to Monitor Vital Signs and Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for monitoring vital signs in residents diagnosed with active COVID-19 infections. This deficiency was identified in 36 out of 40 residents reviewed, where vital signs were not obtained every four hours as ordered. The lapses in monitoring were documented over several days, with some residents not having any vital signs recorded on certain days. This failure to monitor vital signs as per physician orders was a significant deviation from professional standards of care. In addition to the failure in monitoring vital signs, the facility also failed in the administration of medication to a resident at high risk for aspiration. Nursing staff administered oral medication using a 60 ml syringe, which was not within the professional scope of practice for medication administration for this resident. This action posed a significant risk to the resident's health and safety. The deficiencies in monitoring vital signs and medication administration led to an Immediate Jeopardy situation, indicating that the facility's noncompliance had the potential to cause serious harm to residents. The Immediate Jeopardy was identified for multiple federal tags, including F-684, F-726, F-835, F-837, F-867, and F-880, highlighting the substandard quality of care provided by the facility.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across all five hallways observed. Observations revealed multiple large stains of various shades, including brown and bright red, on the carpets of the 100, 200, and 300 hallways. Additionally, several resident rooms were found in disrepair, with issues such as broken furniture, missing trim, exposed drywall, and stained walls and curtains. One room had a broken footboard and an adhesive ribbon hanging from the ceiling with small black bugs attached. Another room had a sink with running water despite the faucet handles being in the shut-off position. Interviews with facility staff, including the Administrator and the VP of Life Safety and Environmental Compliance, confirmed awareness of the environmental issues. The Administrator acknowledged that the facility had been aware of the need for repairs since September 2022 but did not begin addressing these issues until October 2024. The VP of Life Safety and Environmental Compliance confirmed the presence of the stains and the poor condition of the resident rooms and hallways, noting that the bright red stains were from spilled punch beverages, while the source of the brown stains was unidentified.
Expired Food Items Not Discarded in Kitchen
Penalty
Summary
The facility failed to adhere to its food safety guidelines by not discarding expired food items in the kitchen, which had the potential to affect all 99 residents. During an observation of the food preparation area, it was found that an 80-ounce opened bag of grits, an unopened 4-pound roll of deli bologna, and a 12-ounce container of ground allspice were all expired and still available for use. Additionally, a 12-ounce container of ground black pepper was found to be open and not properly sealed, posing a risk of contamination. The Certified Dietary Manager (CDM) confirmed during interviews that these items were expired and had not been discarded, and the black pepper was improperly sealed.
Failure to Implement Baseline Care Plans for COVID-19 Positive Residents
Penalty
Summary
The facility failed to develop and implement baseline care plans for residents admitted with active COVID-19 infections, as required by their policy. The policy mandates that a baseline care plan, which includes instructions for effective and person-centered care, be developed within 48 hours of a resident's admission. However, for four residents with active COVID-19 infections, the facility did not create or implement such plans. This oversight was evident in the cases of residents who were admitted with COVID-19 and other health issues such as shortness of breath, fatigue, muscle weakness, hypertension, difficulty walking, and seizures. Despite physician orders indicating the need for isolation droplet precautions and regular vital signs monitoring, the baseline care plans did not reflect these requirements. The deficiency was further highlighted during an interview with the MDS/Care Plan Coordinator, who confirmed that the baseline care plans for the affected residents did not address the need for isolation or quarantine. This omission failed to alert employees of the necessary precautions, such as wearing personal protective equipment (PPE), to prevent and control the spread of COVID-19 within the facility. The lack of appropriate baseline care plans for these residents with active COVID-19 infections represents a significant lapse in the facility's adherence to its own policies and procedures.
Failure to Revise Care Plans for COVID-19, Falls, and Code Status
Penalty
Summary
The facility failed to ensure timely revisions of care plans for residents who tested positive for COVID-19 during an outbreak. Specifically, the care plans for ten residents were not updated promptly to include COVID-19 isolation requirements and personal protective equipment (PPE) usage as recommended by the CDC. This oversight occurred despite physician orders indicating the need for isolation and PPE. The delay in updating care plans ranged from two to ten days after a positive COVID-19 test, which did not align with the facility's policy of revising care plans when there is a change in a resident's condition. Additionally, the facility did not revise the care plan for a resident identified as a fall risk. Despite an incident where the resident fell, the care plan was not updated to include new interventions such as non-skid footwear or educational signage. Interviews with staff revealed a lack of awareness regarding the resident's fall risk status, and the resident's Kardex did not reflect the necessary fall interventions. This lack of communication and documentation contributed to the deficiency in addressing the resident's fall risk. Furthermore, the facility failed to update the care plan for a resident whose code status changed from full code to Do Not Resuscitate (DNR). The care plan continued to reflect the incorrect code status, which was confirmed by the MDS-Care Plan Coordinator. This discrepancy between the resident's advance directive and the care plan highlights a failure to ensure that critical information is accurately documented and communicated within the facility.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications in two of the four medication carts reviewed. On the A-Wing medication cart, an unopened box of Lorazepam liquid for a resident with severe cognitive impairment was found stored at room temperature instead of in the refrigerator as required. The medication had been on the cart since delivery and was confirmed by the LPN/Risk Manager to have been improperly stored. The pharmacist indicated that the medication would lose effectiveness if not refrigerated and should be discarded after being stored at room temperature for three days. On the C-Wing medication cart, two house stock medications used to treat constipation, Lactulose and Polyethylene Glycol, were found opened and undated. An LPN confirmed that these medications were not stored properly. The facility's policy on medication storage was reviewed, which mandates that medications be stored in medication rooms or carts with proper sanitization, temperature, and moisture control, and that medications requiring refrigeration be stored in designated refrigerators.
Incorrect Tube Feeding Formula Administered
Penalty
Summary
The facility failed to administer the correct tube feeding formula as ordered by the physician for a resident who was dependent on tube feeding for nutrition and hydration. The resident, who had a history of stroke, epilepsy, type 2 diabetes, gastrointestinal bleed, dysphagia, and aphasia, was supposed to receive Glucerna 1.5 at 70 milliliters per hour. However, on January 1, 2025, the resident was mistakenly given Osmolite 1.2, a different tube feeding formula, for approximately 10 hours. This error was discovered by an LPN the following morning, and the correct formula was administered immediately thereafter. The incident was reported to the Director of Nursing and the Medical Director, who confirmed that the resident did not exhibit any signs of distress or discomfort following the administration of the incorrect formula. The facility's policy on feeding tube guidelines emphasizes the importance of administering enteral nutrition as per the practitioner's orders, which was not adhered to in this case. The Executive Director of Nursing expressed that it was expected for nurses to follow the physician's orders accurately.
Failure to Maintain Resident Dignity by Covering Catheter Bag
Penalty
Summary
The facility failed to protect a resident's right to dignity by not covering an indwelling catheter drainage bag, leaving it visible to the public. The resident, who was admitted with diagnoses including neuromuscular dysfunction of the bladder, malignant neoplasm of the urethra, and acute kidney failure, had a moderate cognitive impairment as indicated by a BIMS score of 11. The comprehensive care plan for the resident specified that a privacy bag should be provided to cover the drainage bag at all times. However, during an observation, it was noted that the resident's urinary drainage bag was uncovered and visible from the hallway. A registered nurse confirmed the absence of a privacy dignity cover, resulting in the direct visibility of the urinary drainage bag.
Failure to Protect Residents' Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' protected health information on two of its hallways, D-Wing and C-Wing. On D-Wing, a computer screen on a medication cart was left unattended and unlocked, displaying residents' personal health information. Registered Nurse B confirmed that the screen was not secured, allowing unauthorized individuals potential access to sensitive information. On C-Wing, a resident roster containing sensitive health information was left visible on top of a medication cart. Licensed Practical Nurse A acknowledged that the information was not covered, admitting that she forgot to secure it before leaving the cart. These incidents indicate lapses in following the facility's policies on maintaining the confidentiality of residents' health information.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, leading to deficiencies in care. Resident #36, who had severe cognitive impairment and a gallbladder drain, did not have this critical medical intervention included in their care plan. This oversight was confirmed by the MDS Care Plan Coordinator, who acknowledged the omission during a review of the resident's care plan. Resident #506, who was cognitively intact, tested positive for COVID-19, yet their care plan lacked any interventions related to the infection. Despite having physician's orders for isolation precautions, the care plan was not updated to reflect these necessary interventions. The Director of Nursing confirmed the failure to develop a person-centered care plan for the resident's COVID-19 infection. Additionally, the facility failed to implement care plan interventions for Resident #606, who required one-on-one supervision due to inappropriate sexual behaviors. Observations revealed that the resident was left unsupervised, contrary to the care plan's requirements. Staff members, including CNAs, were not informed of the need for constant supervision. Similarly, Resident #93, who required assistance with meals, was not provided with the necessary support, as evidenced by uneaten meals and staff interviews indicating a lack of awareness of the resident's needs. The MDS Care Plan Coordinator confirmed that the care plan for meal assistance was not implemented.
Failure to Maintain Sanitary Conditions for Respiratory Equipment
Penalty
Summary
The facility failed to maintain and store oxygen equipment in a clean and sanitary condition for two residents. Resident #39, who was admitted with diagnoses including Dementia, Skin Cancer, Depression, and Low Back Pain, was observed on two separate occasions with a nebulizer mask lying uncovered on the nightstand, not stored in a sanitary condition. Licensed Practical Nurse (LPN) C confirmed the unsanitary storage of the nebulizer mask, which was available for resident use. Resident #59, admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, Kidney Disease, and Shortness of Breath, had multiple nebulizer masks in the room, some of which were stored in bags with various dates. One mask, dated 9/22/2024, was observed with a cloudy substance on its surface, attached to the nebulizer machine, and not stored in a bag. LPN A confirmed that the mask was soiled, out of date, and not stored in a sanitary condition. LPN A also stated uncertainty about the cleaning schedule and who was responsible for changing the masks.
Failure to Obtain Physician Order for Bed Rail Use
Penalty
Summary
The facility failed to obtain a physician's order for the use of bed rails for a resident prior to their implementation. The facility's policy requires that a physician or nurse practitioner provide written or verbal orders for residents' care and needs, including the use of bed rails. However, for one resident, who was admitted with diagnoses including Epilepsy, Dehydration, Cerebral Palsy, and Protein-Calorie Malnutrition, the facility did not secure a physician's order for bed rails until after they were already in use. This oversight was confirmed through a review of the resident's medical records and interviews with the facility's nursing staff. The resident had a comprehensive care plan that included the use of padded full side rails for protection against rocking behaviors and seizure activity. Observations confirmed that the resident's bed had padded full bed rails in place before a physician's order was obtained. Interviews with the Assistant Director of Nursing and the Director of Nursing further confirmed that the necessary physician's order was not obtained prior to the use of the bed rails, indicating a lapse in following the facility's policy and procedures for bed rail usage.
Incomplete Pharmacy Review Records for Residents
Penalty
Summary
The facility failed to maintain complete records of pharmacy reviews and the provider's responses to irregularities identified by the pharmacist for two residents. Resident #37, who was admitted with multiple diagnoses including Rheumatoid Arthritis, Chronic Respiratory Failure, and Depression, was found to have medication irregularities noted by the pharmacist on several occasions. However, the medical record did not include separate documents of these irregularities along with the provider's responses. Similarly, Resident #71, admitted with conditions such as Delusional Disorder and Dementia, also had medication irregularities identified by the pharmacist on multiple dates, but the facility did not maintain records of the provider's responses to these irregularities. Interviews with facility staff, including the Medical Record Clerk and the Administrator, confirmed the absence of documentation regarding the pharmacist's recommendations and the provider's responses for both residents. The Vice President of Clinical Services also acknowledged that the facility did not have complete records of the monthly pharmacist reviews and recommendations for these residents, indicating a lapse in maintaining a system of medication records that allows for accurate reconciliation and follow-up on identified pharmaceutical concerns.
Inaccurate Facility Assessment Fails to Reflect Resident Needs
Penalty
Summary
The facility failed to complete an accurate facility-wide assessment to reflect the needs and services provided, which had the potential to affect two residents. The assessment, dated July 18, 2024, did not account for the ethnic, cultural, or personal preferences of the residents, as it stated that no resident fell outside the homogenous local culture and language. However, this was not the case for two residents who had specific needs that were not documented in the assessment. One resident, admitted with diagnoses including Major Depressive Disorder, Anxiety, Intellectual Disability, and Autism, identified as transgender and preferred to be addressed with female pronouns and to dress in female clothing. This preference was documented in her comprehensive care plan but not reflected in the facility assessment. Another resident, admitted with Cerebral Infarction and Dementia, spoke only Russian and required a translator for communication, which was also not captured in the facility assessment. The facility administrator confirmed that the assessment was not accurate and did not reflect these residents' specific needs.
Documentation and Transcription Errors in COVID-19 Testing and Medication Administration
Penalty
Summary
The facility failed to accurately document COVID-19 test results for five residents, leading to inconsistencies in medical records. For several residents, including those with cognitive impairments, there was a lack of documentation for positive COVID-19 test results, despite physician orders and care plans indicating positive diagnoses and necessary precautions. In one case, a resident's test result was incorrectly documented as negative, despite a positive diagnosis and subsequent isolation measures. Additionally, the facility did not obtain a timely urinalysis for a resident with altered mental status, despite multiple orders from nurse practitioners. The nursing staff attempted to collect the urine sample but failed to document their attempts or notify the provider of the difficulties encountered. This resulted in a significant delay in obtaining the necessary test results, which were crucial for diagnosing and treating a potential urinary tract infection. Furthermore, the facility failed to transcribe a physician's order accurately for a resident's medication. Although the correct dosage of Lexapro was administered, the medication administration record did not reflect the updated order for over a year. This transcription error was confirmed by the facility's VP of Clinical Services and the pharmacist, who had processed the correct order. The discrepancy between the administered dosage and the documented order highlights a significant lapse in medication management and record-keeping.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey agency as required by their policy. The policy mandates that any alleged violations involving abuse must be reported to the state agency immediately, but no later than two hours after the allegation is made. In this case, Resident #1, who was cognitively intact with a BIMS score of 15, was involved in an incident where an EMT reported to an LPN that the ER doctor documented vaginal bruising and tearing. However, the facility's investigation found no concerns during a skin assessment, and interviews with the resident and the ER doctor revealed no allegations or documentation of sexual abuse. The facility deemed the allegation as malicious gossip and unsubstantiated, and therefore, did not report it to the State Licensing and Certification Agency. Resident #1 had been admitted to the facility with diagnoses including Unspecified Psychosis, Major Depressive Disorder, and Anxiety. The resident was sent to the ER for evaluation after expressing thoughts of self-harm. Upon return, the EMT's report of potential sexual abuse was not substantiated by further investigation. The facility administrator confirmed that the allegation was not reported because it was considered malicious gossip. This inaction led to a deficiency as the facility did not adhere to its policy of timely reporting alleged abuse to the appropriate authorities.
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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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