Dickson Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Dickson, Tennessee.
- Location
- 901 N Charlotte, Dickson, Tennessee 37055
- CMS Provider Number
- 445477
- Inspections on file
- 17
- Latest survey
- March 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Dickson Health And Rehab during CMS and state inspections, most recent first.
The facility failed to maintain sanitary conditions in the kitchen, with observations of dirty floors, sticky surfaces, and unlogged refrigerator temperatures. Cleaning schedules were not consistently initialed, indicating non-compliance with cleaning protocols. A Registered Dietician confirmed the need for cleanliness and proper logging.
The facility failed to maintain proper infection control practices, as CNAs did not perform hand hygiene during meal pass, and dirty trays were placed with clean ones. PPE was not used during wound care for two residents, and a red biohazard bag with used PPE was found on the floor in a resident's room. Staff interviews revealed a lack of understanding of Enhanced Barrier Precautions.
The facility failed to implement an effective Infection Prevention and Control Program, as staff did not track organisms for UTIs or monitor for outbreaks and cross-contamination. Discrepancies were found in infection surveillance reports, and an LPN admitted to not tracking infections by organism or location. The administrator acknowledged the expectation for infection tracking, highlighting a gap between policy and practice.
The facility lacked a certified Infection Preventionist to oversee the Infection Prevention and Control Program, potentially affecting all 62 residents. An LPN, who had completed training but was not yet certified, was involved. The facility has been without a certified Infection Preventionist since early February, as confirmed by the Administrator.
A facility failed to honor a resident's food preferences, resulting in a deficiency. Despite a policy requiring adherence to individual food preferences, a cognitively intact resident with multiple health conditions reported receiving gravy on meals despite disliking it. An observation confirmed the presence of gravy on the resident's meal, contrary to tray instructions. The RD acknowledged that staff should follow the resident's choices.
A resident's admission assessment was not completed within the required timeframe due to the absence of an MDS coordinator. The assessment, which should have been completed within 13 days, was delayed to 19 days post-admission. The Regional RN confirmed the delay, acknowledging the failure to meet regulatory requirements.
A facility failed to complete a significant change assessment for a resident who enrolled in hospice care. The resident, with Alzheimer's Disease and Dementia, was readmitted to the facility with hospice care to follow. Despite receiving hospice care, the required assessment was not completed within the 14-day timeframe, as confirmed by a Regional RN.
The facility failed to complete resident assessments within the required time frames for two residents. One resident's annual MDS was completed late, while another's discharge MDS was not submitted on time. The Senior Director of Clinical Reimbursement confirmed the delays.
The facility failed to develop comprehensive care plans for two residents, neglecting to address key medical and psychological needs. One resident's care plan omitted Chronic Pain Syndrome and PTSD, while another's did not include dependencies in ADLs, a history of falls, and a Stage 4 pressure ulcer. The absence of an MDS Coordinator contributed to these deficiencies.
The facility failed to update care plans for four residents, neglecting to address specific medical needs such as PTSD, pressure ulcers, and hospice care. A resident with PTSD had no related interventions in their care plan. Another resident with multiple diagnoses lacked care plans for critical areas like pressure ulcers and diabetes. A third resident receiving hospice care had no care plan focus for hospice or antipsychotic use. Lastly, a resident with diabetes and fractures had no care plans for functional abilities and pain.
A resident with multiple medical conditions and dependent on staff for personal hygiene was found to have long, unkempt fingernails with dried debris, despite the facility's policy requiring daily cleaning and regular trimming. Observations and interviews confirmed the deficiency in nail care.
The facility failed to follow physician orders for PRN pain medication, administer medication through a PEG tube correctly, and collaborate with hospice services. A resident received oxycodone for pain levels below the prescribed threshold, another resident's medication was administered without checking stomach contents, and hospice documentation was outdated for a third resident.
A resident with severe cognitive impairment was found with open razors left unattended in their room, contrary to the facility's policy requiring sharp objects to be stored securely. Staff interviews confirmed the oversight, acknowledging the risk posed by the presence of razors, especially with residents who wander.
A facility failed to provide appropriate dialysis care for a resident, lacking a physician's order for hemodialysis, monitoring of the dialysis site, and accurate care planning. The resident, with multiple diagnoses including End Stage Renal Disease, was inaccurately documented as receiving peritoneal dialysis instead of hemodialysis. Staff interviews confirmed the absence of necessary orders and monitoring, and inaccuracies in the care plan were acknowledged.
A facility failed to obtain necessary physician orders for a resident's hospice care and foley catheter. The resident, with multiple diagnoses and cognitively intact, was admitted to hospice care per family request, but no physician's order was documented. Observations confirmed the presence of a foley catheter without a corresponding order. Interviews with an LPN and the DON verified the absence of required orders.
The facility failed to maintain RN coverage for 8 consecutive hours a day, 7 days a week, as required by their policy. Staffing records showed multiple instances of non-compliance in December 2024, January 2025, and February 2025. Interviews revealed challenges with staffing turnover and a negative work environment, contributing to the deficiency. The facility did not use agency staffing, relying on a contract DON.
The facility failed to document monthly pharmacist drug regimen reviews for two residents, one with multiple diagnoses including dementia and another with atrial fibrillation. Both residents were on complex medication regimens, but the facility lacked documentation of reviews or pharmacy recommendations for several months. The Regional Nurse Consultant confirmed the absence of these records, indicating a lapse in the process where the physician was supposed to implement and document the pharmacist's recommendations.
The facility failed to properly store and label medications, as an undated vial of Tuberculin was found in the medication refrigerator, and an RN left a medication cart unattended with unsecured medications. The DON confirmed these actions were against facility policy.
The facility consistently failed to maintain adequate staffing levels on weekends throughout 2024, resulting in a One Star Staffing Rating for all quarters. High turnover due to a negative work environment and ongoing vacancies for a CNA and two LPN positions contributed to the staffing deficiencies. The HR Manager was aware of the low staffing ratings but attributed them to callouts, while the DON was unaware of the issues.
Sanitation Deficiencies in Kitchen and Incomplete Cleaning Logs
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by multiple observations of unclean surfaces and equipment. The kitchen floor was found to be dirty with pieces of paper scattered, and a black rubber floor mat was sticky with crumbs and particles underneath. The deep fryer had a sticky buildup, and the oven handles were sticky with crumbs inside. Additionally, three dry food storage bins had crumbs and a thick sticky area on the outer edge of the lids. The facility also failed to log refrigerator temperatures on the nutrition refrigerator, and there was an undated item found inside. The facility's cleaning schedule showed multiple instances where staff failed to initial that cleaning duties were performed, indicating a lack of adherence to the cleaning schedule. Interviews with staff, including a Registered Dietician, confirmed that the kitchen should be clean and that cleaning logs should be initialed after assignments are completed. The nutrition refrigerator log for March 2025 had no temperatures recorded, and there was an undated pint of chocolate ice cream found. The Registered Dietician confirmed that items in the nutrition refrigerator should be dated and that the temperature log should be filled out daily.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by several observations and interviews. Certified Nursing Assistants (CNAs) D, L, and O did not perform hand hygiene during meal pass, and dirty trays were placed on the cart with clean trays. Additionally, Personal Protective Equipment (PPE) was not used or contained appropriately. During dining observations, CNA L applied gloves without performing hand hygiene and exited the room without removing the gloves. CNA O placed a dirty tray back on the clean cart and assisted a resident with a meal without performing hand hygiene. The Director of Nursing (DON) confirmed that hand hygiene should be performed before putting on gloves and that dirty trays should not be placed on the cart with clean trays. The facility also failed to don PPE when performing wound care for two residents. Resident #1, who was severely cognitively impaired and had a pressure injury, did not have Enhanced Barrier Precautions (EBP) in place during wound care. LPN K and CNA T did not don PPE during the treatment. Similarly, Resident #8, who was moderately cognitively impaired and had a history of recurrent urinary tract infections and diabetic ulcers, did not have PPE donned by LPN K during wound care. Random interviews with staff members revealed a lack of understanding of the proper reasons for using EBP. Furthermore, Resident #38, who was moderately cognitively impaired and tested positive for COVID-19, had a red biohazard bag with used PPE laying on the floor in their room. The DON confirmed that the biohazard bag should not be on the floor. These deficiencies highlight the facility's failure to adhere to infection prevention and control protocols, as outlined in their policies and CDC guidelines.
Failure to Implement Effective Infection Control Program
Penalty
Summary
The facility failed to establish and implement an effective Infection Prevention and Control Program, as evidenced by the inability to track organisms being treated and monitor for outbreaks and cross-contamination. The policy review and interviews revealed that the facility's program was not adequately identifying, reporting, investigating, and controlling infections and communicable diseases. Specifically, the facility did not track the organisms responsible for urinary tract infections (UTIs) in residents, which is crucial for monitoring potential outbreaks and cross-contamination. This deficiency was noted in the monthly infection surveillance reports for December 2024, January 2025, and February 2025, where the organisms being treated for UTIs were not listed, and discrepancies were found between the infection maps and surveillance reports. Interviews with LPN G highlighted a lack of knowledge and training in monitoring infections by organism and area within the facility. LPN G admitted to not tracking infections by organism or location and was unaware of the types of bacteria that would require isolation. Furthermore, LPN G confirmed that the information from the electronic medical record system was not correctly transferring to the infection surveillance reports, a problem that was only identified during the survey. The facility administrator acknowledged the expectation for infections to be tracked to monitor trends and cross-contamination, indicating a gap between policy and practice.
Lack of Certified Infection Preventionist in Facility
Penalty
Summary
The facility failed to provide a qualified Infection Control Preventionist responsible for monitoring and maintaining the Infection Prevention and Control Program, potentially affecting all 62 residents. According to the Centers for Medicare & Medicaid Services guidelines, facilities are required to have at least a part-time Infection Preventionist who must work onsite and cannot be an off-site consultant. The Infection Preventionist's role is crucial for mitigating infectious diseases, and specialized training is required. During interviews, an LPN admitted to not being certified yet, despite having completed the training. The facility has been without a certified Infection Preventionist since February 6, 2025, as confirmed by the Administrator.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, leading to a deficiency in promoting and facilitating resident self-determination. The facility's policy on resident food preferences, dated October 2024, mandates that nutritional assessments include evaluations of individual food preferences and that residents receive food prepared according to their needs and preferences. Despite this policy, a resident with diagnoses including Chronic Obstructive Pulmonary Disease, Morbid Obesity, Muscle Weakness, Bariatric Surgery Status, and Gastro-Esophageal Reflux Disease, who was cognitively intact with a BIMS score of 15, reported that they disliked gravy but continued to receive it on their meals. An observation of the resident's lunch tray confirmed the presence of gravy on the meat, contrary to the meal card instructions that specified 'No Gravy.' The Registered Dietician acknowledged that staff should adhere to the resident's choices.
Failure to Complete Timely Admission Assessment
Penalty
Summary
The facility failed to complete a comprehensive resident admission assessment within the required timeframe for one of the sampled residents. According to the Resident Assessment Instrument (RAI) Manual Version 3.0, the Minimum Data Set (MDS) and Care Area Assessment (CAA) for an admission assessment must be completed no later than 13 days after the resident's entry date. However, for Resident #215, who was admitted with multiple diagnoses including wedge compression fractures, acute respiratory failure, unspecified cirrhosis of the liver, and chronic systolic congestive heart failure, the admission MDS assessment was completed 19 days after admission, exceeding the required timeframe. The delay in completing the admission assessment was attributed to the facility being without an MDS coordinator since the end of January 2025. The Regional Registered Nurse, who was overseeing the assessments, confirmed during an interview that the admission MDS should be completed within 14 days of admission and acknowledged that the assessment for Resident #215 was not completed in a timely manner. This oversight resulted in a deficiency as the facility did not adhere to the regulatory requirements for timely resident assessments.
Failure to Complete Significant Change Assessment for Hospice Enrollment
Penalty
Summary
The facility failed to complete a significant change assessment for Resident #57, who was one of 21 residents reviewed. According to the CMS Resident Assessment Instrument (RAI) Version 3.0 Manual, a significant change assessment must be completed within 14 days when a resident enrolls in a hospice program. Resident #57, who had diagnoses including Alzheimer's Disease, Dementia, Hyperlipidemia, and Hypothyroidism, was readmitted to the facility with hospice care to follow. The Quarterly Minimum Data Set (MDS) indicated that the resident received hospice care during the assessment reference period. However, a significant change MDS was not completed within the required timeframe, as confirmed by a Regional Registered Nurse during a telephone interview.
Failure to Timely Complete Resident Assessments
Penalty
Summary
The facility failed to complete resident assessments using the Centers for Medicare & Medicaid Services-specific Resident Assessment Instrument (RAI) process within the regulatory time frames for two residents. According to the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, the Care Area Assessment (CAA) Completion Date for an admission assessment must be no later than 13 days after the entry date, and for an annual assessment, it must be no later than 14 days after the Assessment Reference Date (ARD). However, the facility did not adhere to these timelines for Resident #28 and Resident #48. Resident #28, who was admitted with diagnoses including diabetes, dementia, and depression, had an annual MDS with an ARD of 12/13/2024, but the completion date was 1/13/2025, exceeding the required completion date of 12/27/2024. Similarly, Resident #48, with conditions such as peripheral vascular disease and end-stage renal disease, had a discharge MDS with a completion date of 3/3/2025 that had not been submitted. The Senior Director of Clinical Reimbursement confirmed during interviews that the MDS submissions for both residents were not timely.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical and psychological needs. Resident #55, who was admitted with Chronic Obstructive Pulmonary Disease, Chronic Pain Syndrome, and PTSD, had a care plan that did not address the Chronic Pain Syndrome or PTSD. Despite having a BIMS score indicating moderately impaired cognition and requiring assistance with various activities of daily living, the care plan only focused on issues like Alcohol Dependence and Insomnia. The Director of Nursing confirmed that the care plan should have included the resident's pain and PTSD. Resident #215, admitted with multiple diagnoses including wedge compression fractures, acute respiratory failure, and chronic systolic congestive heart failure, had a care plan that only addressed transfer status and risk for altered nutritional/hydration status. The resident's Admission MDS assessment indicated no cognitive impairments but highlighted dependencies in toileting, dressing, and personal hygiene, as well as a history of falls and a Stage 4 pressure ulcer. The CAA Summary triggered care areas such as ADL function, urinary incontinence, falls, pressure ulcer, and pain, but these were not included in the care plan. The facility had been without an MDS Coordinator, which contributed to the oversight in care planning.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update or revise the care plans for four residents, leading to deficiencies in addressing their specific medical needs. Resident #55, who was admitted with diagnoses including PTSD, had a care plan that did not address the risk related to PTSD, despite having a moderately impaired cognition and requiring staff assistance with ADLs. The Director of Nursing confirmed that the PTSD diagnosis should have been included in the care plan. Resident #56, admitted with multiple diagnoses including Pneumonia and Diabetes, had a care plan that lacked focus on several critical areas such as vision, communication, ADLs, urinary incontinence, and pressure ulcers, despite these being triggered in the Care Area Assessment Summary. The resident also had an unstageable deep tissue injury that was not included in the care plan, and the Registered Dietician and Regional RN confirmed the absence of necessary care plan focuses. Resident #57, with Alzheimer's Disease and receiving hospice care, had a care plan that did not reflect a focus for hospice or the use of antipsychotics, despite receiving such medications. The Regional RN confirmed the absence of these focuses in the care plan. Similarly, Resident #220, with a history of fractures and diabetes, had a care plan that did not address functional abilities, urinary incontinence, pressure ulcers, and pain, even though these were marked for care planning in the CAA Summary.
Failure to Maintain Resident's Nail Hygiene
Penalty
Summary
The facility failed to ensure that a resident had clean and groomed fingernails, as required by their policy on nail care. The policy, dated October 2024, mandates daily cleaning and regular trimming of nails to prevent infections. However, observations and interviews revealed that the resident had long, unkempt fingernails with dried brown debris underneath, indicating a lack of proper nail care. The resident, who was admitted with multiple medical conditions including wedge compression fractures, acute respiratory failure, cirrhosis of the liver, and chronic systolic congestive heart failure, was dependent on staff for personal hygiene. Despite receiving showers and bed baths on specific dates, the resident's fingernails remained unclean, as confirmed by both the resident and the Director of Nursing during observations on March 3 and March 4, 2025.
Deficiencies in Medication Administration and Hospice Collaboration
Penalty
Summary
The facility failed to adhere to physician orders for the administration of PRN pain medication for a resident diagnosed with Atrial Fibrillation, Adult Failure to Thrive, and Radiculopathy. The resident, who was cognitively intact, received oxycodone for pain levels below the prescribed threshold of 7 on multiple occasions across several months, contrary to the physician's orders. The Director of Nursing confirmed that physician orders with specific parameters should be followed, indicating a lapse in compliance with medication administration protocols. Another deficiency involved the administration of medication through a PEG tube for a resident with Cerebral Palsy, Heart Failure, and Gastrostomy. The facility's policy required checking for residual stomach contents before administering medication, and if more than 100 ml was present, the medication should be withheld, and the physician notified. However, during an observation, an LPN failed to aspirate stomach contents before administering medication, which was confirmed as a necessary step by the Director of Nursing. Additionally, the facility did not maintain proper collaboration with hospice services for a resident with Parkinson's Disease, Dementia, and Anxiety. The care plan indicated the resident was receiving hospice services, but the last hospice documentation in the resident's record was from nearly a year prior. An LPN was unable to provide current hospice documents or evidence of collaboration with the hospice agency, as required by the facility's policy.
Failure to Secure Sharp Objects in Resident's Room
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for one resident, identified as Resident #34, who was found with open razors left unattended in their room. The facility's policy on needlesticks and cuts, dated April 2024, mandates that sharp objects should be placed in puncture-resistant containers to prevent injuries. Despite this policy, observations on multiple occasions revealed two blue disposable razors on Resident #34's nightstand. Interviews with staff, including CNAs and an LPN, confirmed that razors should not be left in resident rooms and should be stored in a secured area such as the shower room or central supply. Resident #34, who was admitted with diagnoses including severe cognitive impairment, muscle weakness, and restlessness, required supervision for personal hygiene. The resident's condition, combined with the presence of razors in their room, posed a potential risk. Staff acknowledged the oversight, noting that the facility had residents who wander, which further emphasized the need for secure storage of sharp objects. The facility administrator also confirmed that razors should not be in resident rooms and should be locked away to ensure safety.
Deficiencies in Dialysis Care for a Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident requiring such services. The deficiencies included the absence of a physician's order for the resident's hemodialysis treatments, lack of assessment and monitoring of the dialysis site for thrill and infection, failure to record weights and vital signs, and an inaccurate individualized care plan. The facility's policies on comprehensive care plans and dialysis care were not adhered to, as evidenced by the lack of documentation and communication with the dialysis clinic. The resident involved was admitted with diagnoses including Peripheral Vascular Disease, End Stage Renal Disease, Chronic Pain Syndrome, and Diabetes. The care plan inaccurately indicated that the resident received peritoneal dialysis, while the resident actually underwent hemodialysis. Interviews with facility staff confirmed the absence of necessary orders and monitoring, and the Senior Director of Clinical Reimbursement acknowledged the inaccuracies in the care plan.
Lack of Physician Orders for Hospice and Foley Catheter
Penalty
Summary
The facility failed to obtain a physician's order for hospice care and a foley catheter for Resident #53. The facility's policy requires a physician's order for hospice services and immediate care orders for residents. Resident #53 was admitted with diagnoses including Pleural Effusion, Type 2 Diabetes Mellitus, Atrial Fibrillation, and Diastolic Congestive Heart Failure. The resident was cognitively intact with a BIMS score of 13. Despite being admitted to hospice care per family request, there was no physician's order documented for hospice services or the foley catheter observed in the resident's room. Observations on 3/4/2025 confirmed the presence of a foley catheter without a corresponding physician's order. Interviews with an LPN and the DON confirmed the absence of required physician orders for both the foley catheter and hospice services.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, as required by their policy. The policy, dated March 2025, mandates that the community provides licensed nursing staff 24 hours a day, 7 days a week. However, a review of the facility's RN staffing records revealed multiple instances where this requirement was not met. Specifically, there was no RN coverage for 8 consecutive hours on several dates in December 2024, January 2025, and February 2025. This deficiency was confirmed through a review of the facility's staffing records and interviews with staff members. Interviews with the facility's staffing coordinator and Director of Nursing (DON) revealed challenges in maintaining adequate RN coverage due to staffing turnover and a negative work environment. The staffing coordinator acknowledged periods without a full-time DON, and the current DON, who started in February, was unaware of any concerns related to RN coverage. The facility had previously employed a travel contract DON from November 2024 through February 2025. The Administrator also acknowledged concerns with RN coverage and noted that the facility did not use agency staffing, relying instead on a contract DON.
Failure to Document Monthly Pharmacist Drug Regimen Reviews
Penalty
Summary
The facility failed to provide evidence of a monthly pharmacist drug regimen review for two residents, which is a requirement to ensure the safe administration of medications. Resident #38, who has multiple diagnoses including Type 2 Diabetes Mellitus, Heart Failure, Dementia, and Hypertension, was prescribed several medications such as Risperdal, Depakote, Hydrocodone-Acetaminophen, Duloxetine, and Trazodone. Despite the complexity of the medication regimen and the resident's moderate cognitive impairment, the facility did not have documentation of medication regimen reviews or pharmacy recommendations for December 2024, January 2025, and February 2025. Similarly, Resident #44, diagnosed with Atrial Fibrillation, Adult Failure to Thrive, and Radiculopathy, was prescribed medications including Buspirone, Eliquis, Duloxetine, Furosemide, and Oxycodone. The resident was cognitively intact, as indicated by a BIMS score of 13. However, the facility also failed to provide documentation of medication regimen reviews or pharmacy recommendations for the same months. During an interview, the Regional Nurse Consultant acknowledged the absence of these records, noting that the pharmacist's reports were supposed to be implemented by the physician and scanned into the resident's chart, which had not occurred.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as evidenced by two specific incidents. Firstly, an opened multi-dose vial of Tuberculin Purified Protein Derivative was found undated in the medication refrigerator in the East medication room. This was confirmed during an observation with an LPN and later acknowledged by the Director of Nursing (DON) during an interview. The facility's policy requires that medications with shortened expiration dates be labeled with the date they were opened, which was not adhered to in this instance. Secondly, during a medication administration, an RN left a medication cart unattended with several medications unsecured on top. The medications included Cozaar, Methocarbamol, Hydroxyzine HCL, Estradiol, Fluoxetine HCL, Acetaminophen, Omeprazole, and Docusate sodium. This action was contrary to the facility's policy, which mandates that medications should not be left unattended. The DON confirmed that medications should be secured and not left out, indicating a lapse in adherence to the facility's medication storage and administration protocols.
Inadequate Weekend Staffing and Low Staffing Ratings
Penalty
Summary
The facility failed to maintain adequate staffing levels on weekends for three out of four quarters in 2024, resulting in a One Star Staffing Rating for all four quarters. The facility's policy mandates 24/7 licensed nursing staff to ensure resident safety and well-being, but the Quarterly Payroll Based Journal (PBJ) reviews revealed excessively low weekend staffing and consistently low overall staffing ratings. Interviews with staff indicated a high turnover rate due to a negative work environment, contributing to the staffing shortages. The Staffing Coordinator acknowledged the turnover issues, while the Director of Nursing (DON) was unaware of the low weekend staffing concerns and the One Star Staffing Rating. The Administrator confirmed the staffing deficiencies and noted that the Human Resource Manager was responsible for entering PBJ data. The HR Manager was aware of the low staffing ratings but attributed them to callouts without providing a specific cause. The facility had ongoing vacancies for one Certified Nurse Assistant (CNA) and two Licensed Practical Nurse (LPN) positions, further exacerbating the staffing challenges.
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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