Donalson Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fayetteville, Tennessee.
- Location
- 1681 Winchester Highway, Fayetteville, Tennessee 37334
- CMS Provider Number
- 445173
- Inspections on file
- 20
- Latest survey
- March 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Donalson Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions was found to have a dislocated femoral head during a hospital visit. The injury, classified as of unknown origin, was not reported to the facility's Administrator until over two days later, violating the facility's policy for immediate reporting. The delay was confirmed by the Director of Nursing and the Administrator, who emphasized the requirement for prompt notification of such incidents.
Two residents with severe cognitive impairment had handwritten signs displaying personal medical information posted in their rooms, visible to anyone entering. These signs were not requested by the residents or their representatives, and the DON confirmed staff posted them, resulting in a failure to maintain resident dignity and privacy.
The facility did not resubmit PASRR referrals to the state agency after two residents were diagnosed with new mental health conditions, including neurocognitive disorder, paranoia, delusional disorders, panic disorder, and anxiety disorder. Despite facility policy requiring prompt referral for Level II PASRR review when new diagnoses are identified, the Social Services Director confirmed that updated PASRR submissions were not made to reflect these changes.
Licensed nurses administered antihypertensive medications to three residents despite physician orders to hold the medications for low systolic blood pressure (SBP). In each case, the medication was given when the SBP was below the specified threshold, and staff did not notify the physician or obtain approval to proceed. The DON confirmed that medications should have been held according to orders, and no adverse outcomes were documented.
A resident with a feeding tube and severe cognitive impairment did not receive physician-ordered free water flushes because the feeding pump was not programmed to deliver the prescribed hydration. The issue was discovered during observation and confirmed by the ADON and NP, who noted the resident was not receiving the water flush as ordered.
A resident received insulin glargine from a medication cart where the insulin pen was not labeled with an open or expiration date, contrary to facility policy and manufacturer guidelines. The insulin was administered without verification of its expiration status, and staff confirmed the labeling omission and improper use.
A resident with hypertension received Lisinopril despite medical record entries showing systolic blood pressure below the physician-ordered threshold. Staff reported rechecking blood pressure before administration but failed to document the updated readings in the medical record, resulting in incomplete and inaccurate documentation. The DON confirmed that accurate documentation of blood pressures is expected.
Staff failed to provide hand hygiene assistance to several residents before meals, did not consistently use required PPE for residents on Enhanced Barrier Precautions during direct care, and did not perform hand hygiene during medication administration. These actions were contrary to facility policies and were confirmed by staff interviews and direct observation.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in a timely manner for a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's Disease and a recent femoral fracture. The resident was transferred to the emergency department due to gastrointestinal bleeding, where a computed tomography angiogram revealed a dislocation of the femoral head. Despite this finding, the injury was not reported to the facility's Administrator until over two days later, contrary to the facility's policy requiring immediate reporting of such incidents. The Director of Nursing and the Administrator confirmed that the facility's policy was not followed, as staff are expected to report any injury of unknown origin immediately. Registered Nurse D, who became aware of the injury, did not report it promptly, citing a lapse in memory regarding the incident. This delay in reporting was acknowledged during interviews with the Director of Nursing and the Administrator, who reiterated the expectation for immediate notification of any suspicious injuries.
Failure to Protect Resident Dignity and Privacy Due to Visible Medical Signage
Penalty
Summary
The facility failed to maintain the dignity and privacy of two residents by allowing medical information to be visibly posted in their rooms without the request or consent of the residents or their representatives. For one resident with severe cognitive impairment and diagnoses including Parkinson's Disease, Dementia, and Adult Failure to Thrive, a handwritten sign stating 'No Briefs to [Resident] D/T groin' was posted above the television and was visible to anyone entering the room on multiple occasions. There was no evidence in the care plan that the resident or their representative had requested this signage. Similarly, another resident with severe cognitive impairment and diagnoses including Dementia, Diabetes, and Anxiety had a handwritten sign posted above the television stating 'We are going back to [medicated cream] to [Resident]'s Buttocks. Please wash skin gently.' This sign was also visible to anyone entering the room on several occasions, and there was no documentation that the resident or their representative had requested the sign. The Director of Nursing confirmed that staff posted these signs and acknowledged that this practice failed to maintain the residents' dignity and privacy.
Failure to Resubmit PASRR Referrals After New Mental Health Diagnoses
Penalty
Summary
The facility failed to resubmit Pre-Admission Screening and Resident Review (PASRR) referrals to the state agency after new mental health diagnoses were identified for two residents. According to facility policy, any resident exhibiting a newly evident or possible serious mental disorder or related condition must be promptly referred for a Level II PASRR review. For one resident, the medical record showed initial PASRR screening included diagnoses of depression and anxiety, but subsequent diagnoses of neurocognitive disorder with Lewy Bodies, paranoia, and delusional disorders were not reported through a new PASRR submission. The Social Services Director confirmed that the most recent PASRR referral was not updated to reflect these new diagnoses. For another resident, the initial PASRR screening included major depression and dementia, but later diagnoses of panic disorder and anxiety disorder were not added to the PASRR. The Social Services Director attempted to update the PASRR to include new medications but was unable to add the new diagnoses, and confirmed that the PASRR had not been resubmitted after the new mental health conditions were identified. Both cases demonstrate that the facility did not coordinate assessments with the PASRR program as required by policy, resulting in a failure to refer residents for appropriate review after significant changes in their mental health status.
Failure to Follow Physician Orders for Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to follow physician's orders regarding the administration of blood pressure medications for three residents who had specific parameters for holding antihypertensive medications based on systolic blood pressure (SBP) readings. Facility policy required licensed nurses to administer medications as ordered, including holding medications if vital signs were outside prescribed parameters and documenting these actions on the medication administration record (MAR). However, medical record reviews revealed that medications were administered to residents even when their SBP was below the threshold specified in the physician's orders. For one resident with hypertension and cognitive communication deficit, Losartan was ordered to be held if SBP was less than 110. Despite this, the medication was administered on multiple occasions when the resident's SBP was below the ordered parameter. Interviews with the LPNs involved confirmed that they administered the medication despite the low SBP and did not notify the physician or obtain approval to proceed. The DON confirmed that the medication should have been held and that the expectation was for staff to follow physician's orders. Similar deficiencies were found for two other residents with orders for Metoprolol to be held for SBP below specified levels. In both cases, the medication was administered when SBP readings were below the ordered parameters, and the nurses involved acknowledged the error during interviews. The DON reiterated that medications should have been held in these situations. No adverse outcomes were documented for any of the residents involved.
Failure to Administer Ordered Water Flushes via Feeding Tube
Penalty
Summary
A deficiency occurred when a resident with a gastrostomy tube and severe cognitive impairment did not receive physician-ordered free water flushes at 60 ml/hr for 22 hours per day. The resident's care plan and medical orders specified the need for continuous tube feeding and water flushes, but during observation, the water flush bag was found full and connected to the feeding pump, which had not been programmed to deliver the water flush as ordered. The Assistant Director of Nursing (ADON) confirmed that the pump was not set to administer the water flush and that the resident was not receiving the prescribed hydration. The ADON explained that the feeding pump had been placed on hold during medication administration and may not have been properly resumed to include the water flushes. The issue was identified during a review and confirmed through interviews with both the ADON and the Nurse Practitioner, who acknowledged that the resident had not received the water flush as ordered. The resident was assessed and found to have no adverse outcomes from the missed water flushes.
Failure to Label Insulin Pen with Open and Expiration Dates
Penalty
Summary
The facility failed to ensure that an insulin medication was properly labeled with an open and expiration date in one of four medication carts observed, which had the potential to affect a resident who was receiving insulin therapy. Facility policy required insulin pens to be clearly labeled with the resident's name and expiration date, and to be discarded if the label was missing or if the pen was expired. Manufacturer's guidelines also specified that insulin glargine pens should not be used for more than 28 days after first use. During observation, an insulin glargine pen in the medication cart was found to be opened and not labeled with an open date for the resident. The Infection Preventionist confirmed that the insulin pen was the only one available for the resident and that it had been used for medication administration without proper labeling, making it impossible to verify if it was within the 28-day expiration period. The Director of Nursing and the Pharmacist both confirmed that insulin medications should be checked for expiration dates prior to administration and that the insulin should have been labeled with an open date and expiration date upon first use. The improperly labeled insulin glargine was administered to the resident, who had a history of diabetes, hypertension, and muscle weakness, and was cognitively intact according to recent assessments. The Medication Administration Record showed that the resident received insulin as ordered, and blood sugar levels remained at baseline with no negative outcomes reported. However, the lack of proper labeling meant that the facility could not ensure the medication's effectiveness or compliance with policy and manufacturer guidelines.
Failure to Accurately Document Blood Pressure Readings Prior to Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records for one resident who was prescribed Lisinopril for hypertension. According to the facility's policy, all medications administered must be ordered by a physician and nursing personnel are responsible for proper documentation. The resident, who was cognitively intact and had diagnoses including anxiety, hypertension, and depression, had a physician's order for Lisinopril to be held if the systolic blood pressure (SBP) was less than 120. However, the Medication Administration Record (MAR) showed that Lisinopril was administered on several occasions when the recorded SBP was below 120. Interviews with the staff involved revealed that both the Infection Preventionist (IP) and an LPN stated they would recheck the blood pressure if the SBP was less than 120 before administering the medication, but they failed to document the rechecked blood pressure in the medical record. The Director of Nursing (DON) confirmed that it was her expectation for blood pressures to be documented accurately in the medical record. This lack of accurate documentation led to a deficiency in maintaining complete and accurate medical records for the resident.
Infection Control Lapses in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to implement its infection prevention and control program as evidenced by multiple lapses in hand hygiene and use of personal protective equipment (PPE) during resident care and meal service. Staff did not offer or assist with hand hygiene for five residents prior to meals, despite facility policy requiring this practice. Observations showed that staff delivering meal trays to residents in their rooms did not provide hand hygiene assistance, and interviews with staff confirmed that this was not routinely done for residents eating in their rooms, even though it was acknowledged as necessary by both the Infection Preventionist (IP) and the Director of Nursing (DON). Additionally, the facility did not ensure that staff donned appropriate PPE for residents on Enhanced Barrier Precautions (EBP). In two observed cases, staff provided direct care, such as changing briefs and linens, to residents on EBP while wearing only gloves and not gowns, contrary to facility policy and care plans. Staff interviews revealed a lack of consistent understanding and communication regarding which residents required EBP and the specific PPE needed. There was also confusion about how outside care providers and families would be informed of EBP requirements. Further deficiencies were observed in hand hygiene practices during medication administration. The IP was seen providing care to one resident, then preparing and administering medication to another resident without performing hand hygiene before or after the process, despite facility policy mandating hand hygiene at these times. The IP and DON both confirmed that hand hygiene should have been performed before and after resident contact and medication administration, but this was not done.
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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