Eaton Creek Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Nashville, Tennessee.
- Location
- 4343 Ashland City Highway, Nashville, Tennessee 37218
- CMS Provider Number
- 445262
- Inspections on file
- 19
- Latest survey
- February 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Eaton Creek Post Acute during CMS and state inspections, most recent first.
A CNA transferred a dependent, non-English speaking resident with multiple medical conditions from a shower bed to a regular bed without the required second staff member and failed to lock all shower bed wheels, causing the resident to fall between the beds and sustain a left humeral neck fracture and multiple bruises. The incident was not reported or documented at the time, and the resident's pain and injuries went unrecognized for several days until discovered by another CNA, resulting in delayed medical intervention.
A LTC facility failed to protect residents from abuse and neglect, resulting in Immediate Jeopardy. A cognitively impaired resident was found in a compromising position with another resident due to inadequate supervision. Another resident alleged sexual assault by a fellow resident, causing psychosocial harm. The facility also failed to address a resident's substance abuse history, leading to an overdose, and did not intervene when a resident with an intellectual disability was physically abused by a family member. Additionally, a staff member verbally abused a resident.
The facility administration failed to manage operations effectively, leading to abuse, neglect, and significant weight loss among residents. Incidents included unaddressed abuse, delayed reporting of allegations, and inadequate nutritional support. The administration also failed to follow up on a resident's drug history, resulting in an overdose. The QAPI plan was not maintained, and the governing body did not provide necessary oversight.
The facility's Governing Body failed to provide adequate oversight for the QAPI Program, resulting in a lack of effective plans to address and investigate allegations of abuse and neglect, as well as nutritional needs. This led to significant weight loss among residents and an Immediate Jeopardy situation. The facility did not establish or implement interventions to address these concerns, and interviews confirmed the Governing Body's responsibility for the QAPI program.
The QAPI Committee at the facility failed to effectively identify, report, and address incidents of abuse and significant weight loss among residents. Multiple incidents of abuse were not properly intervened or documented, and systemic failures in monitoring nutritional status led to severe weight loss in several residents. The facility's administration and Governing Body did not provide adequate oversight, resulting in significant deficiencies in the quality of care.
The facility failed to report allegations of abuse and neglect within the required timeframe, resulting in Immediate Jeopardy. A resident reported a sexual assault by another resident, which was not reported to the State Survey Agency within 2 hours. Additionally, a resident's cocaine overdose was reported a day late, and another incident of sexual abuse was reported over three hours late. These delays in reporting violated the facility's policies and resulted in a citation for substandard quality of care.
The facility failed to conduct thorough investigations into multiple allegations of abuse and neglect involving several residents. In one case, a cognitively impaired resident was allegedly involved in a sexual abuse incident with another resident, but the investigation was inadequate and did not include all relevant witness statements or consider the police report. Another incident involved a resident who alleged sexual assault, resulting in psychosocial harm and delayed incontinence care, but the investigation was insufficient and lacked comprehensive documentation. Additionally, the facility did not adequately investigate a resident's cocaine overdose, leading to an Immediate Jeopardy situation and substandard quality of care.
The facility failed to assess and address the nutritional needs of several residents, leading to significant weight loss. Systemic failures included inadequate monitoring and documentation of meal intake, and insufficient assistance during meals. Residents experienced severe weight loss, with many meal intakes undocumented. Staff interviews revealed a lack of awareness and communication regarding residents' dietary needs, resulting in Immediate Jeopardy.
A resident with a history of elopement and multiple diagnoses, including dementia, managed to exit a facility through a window, remaining unnoticed for over 8 hours. Despite having a wander guard and a care plan, inadequate supervision and monitoring led to the resident being found 3 miles away. Staff failed to conduct required rounds, and the resident's room was not properly identified, contributing to the oversight.
A resident's Hydrocodone medication was misappropriated in an LTC facility. The facility's investigation was incomplete, failing to determine responsibility for the missing medication. An agency nurse, who was on duty during the discrepancy, refused drug testing and did not return to the facility. The resident, with chronic pain, did not receive documented doses of the medication as per the physician's order.
The facility failed to ensure proper documentation and communication during resident transfers, as evidenced by incomplete transfer forms and missing physician orders for six residents. For instance, a resident was transferred without a completed form, and the family was not notified. Other residents were transferred without documented orders or completed forms, leading to inadequate communication with receiving hospitals.
The facility failed to provide bed-hold notices to residents or their representatives during transfers to hospitals or therapeutic leave, as required by policy. This deficiency affected five residents, including those with severe cognitive impairments and acute medical conditions. The DON acknowledged the lack of documentation for bed-hold forms in each case.
Two residents with head lice were not provided with updated care plans reflecting necessary isolation precautions. Despite orders for lice-killing shampoo, the care plans lacked interventions for the lice condition. Interviews with staff confirmed the oversight, highlighting a deficiency in the facility's care planning process.
A resident dependent on staff for personal hygiene did not receive adequate bathing services as per the facility's policy. Over several months, the resident received significantly fewer bed baths than scheduled and no showers, despite being dependent on staff for ADLs. Interviews revealed staffing issues and heavy workloads contributed to the deficiency.
The facility failed to document physician orders for medication administration for two residents. One resident was given Haldol without a documented order after becoming combative, and another was administered simethicone following a verbal order without proper documentation. The DON and ADON acknowledged the absence of required orders, indicating a lapse in following the facility's policies for medication administration.
The facility failed to prevent and adequately care for pressure ulcers in two residents, resulting in the development of a Stage IV ulcer in one resident. Despite being at risk for impaired skin integrity, the resident's ulcer was not discovered until it had progressed significantly, indicating a lapse in weekly skin audits and communication among nursing staff.
The facility failed to maintain adequate nursing staff, impacting resident safety and well-being. The facility assessment indicated a staffing plan, but actual staffing levels were insufficient, particularly on weekends and nights. Interviews revealed high reliance on agency staff, unmet resident needs, and high staff turnover, with key positions remaining unfilled.
The facility did not maintain the required RN coverage for 8 consecutive hours on two days in June 2024. This deficiency was confirmed through a review of the facility's assessment, licensure checklist, and employee time sheets. The Administrator acknowledged the staffing shortage and the absence of an RN on those days.
Failure to Provide Adequate Supervision and Safe Transfer Resulting in Resident Harm
Penalty
Summary
A certified nursing assistant (CNA) attempted to transfer a resident with significant physical and cognitive impairments from a shower bed to the resident's bed without the required assistance of a second staff member. The resident was dependent on staff for all activities of daily living, required two-person assistance for transfers, and had a history of multiple complex medical conditions, including heart failure, diabetes, muscle weakness, and moderate cognitive impairment. The CNA did not lock all the wheels on the shower bed, specifically forgetting to secure the bottom wheels, which resulted in the shower bed shifting during the transfer. This caused the resident's legs to fall between the beds and the upper body to become stuck, leading to an acute, mildly displaced fracture of the left humeral neck, as well as multiple bruises and soft tissue swelling. The incident was not reported at the time it occurred. The CNA did not notify the charge nurse or any supervisory staff, as required by facility policy, and did not document the event. Over the following days, the resident exhibited signs of pain, including moaning and non-verbal cues, but there was no documentation of pain assessments or administration of pain medication. The resident's condition, including swelling and bruising, was only discovered several days later by another CNA during routine care, who then notified the nurse on duty. Subsequent medical evaluation confirmed the fracture and additional injuries, and the resident was transferred to the hospital for further assessment and treatment. Facility policies required immediate reporting of accidents, completion of event notes, provider notification, and implementation of new interventions following incidents. The policies also specified that residents requiring two-person assistance for transfers must not be moved by a single staff member. In this case, the CNA acted alone, failed to follow safety protocols, and did not report the incident, resulting in a delay in the identification and treatment of the resident's injuries. The resident, who was non-English speaking and had difficulty communicating, was dependent on staff for all care and unable to advocate for herself, further contributing to the delay in appropriate response.
Failure to Prevent Abuse and Neglect in LTC Facility
Penalty
Summary
The facility failed to provide an environment free from abuse for several residents, resulting in Immediate Jeopardy. A cognitively impaired resident with wandering tendencies was found in a compromising position with another resident, indicating a lack of supervision and intervention by staff. The facility's failure to supervise and intervene placed both residents at risk of sexual abuse. Additionally, the facility did not adequately address the wandering behavior of the cognitively impaired resident, which had been documented multiple times prior to the incident. Another incident involved a resident who alleged that a fellow resident entered her room, naked from the waist down, and attempted to sexually assault her. This incident caused psychosocial harm to both the victim and her roommate. The facility's failure to prevent this incident and to provide adequate supervision and intervention contributed to the Immediate Jeopardy situation. The facility also failed to recognize and address a resident's history of substance abuse, resulting in an overdose and hospitalization. Furthermore, a resident with an intellectual disability was physically abused by a family member, and staff failed to intervene effectively. Additionally, a staff member verbally abused a resident, although this did not rise to the level of Immediate Jeopardy. These incidents highlight the facility's failure to protect residents from various forms of abuse and neglect, leading to a citation for substandard quality of care.
Facility Administration Fails to Prevent Abuse and Neglect
Penalty
Summary
The facility administration failed to effectively manage and oversee the operations, leading to multiple instances of abuse, neglect, and significant weight loss among residents. The administration did not provide adequate oversight of clinical staff, resulting in a lack of intervention in cases of observed abuse and delayed reporting of allegations. Specific incidents included a resident being found in a compromising position with another resident, and staff failing to intervene immediately. Another resident reported a sexual assault, but the allegation was not reported until the following day, and the administration did not thoroughly investigate the incident. The administration also failed to address the nutritional needs of residents, resulting in significant weight loss for several individuals. The facility did not monitor meal consumption or provide necessary assistance to residents during meals, contributing to their declining nutritional status. Additionally, the administration did not implement a process to follow up on a resident's history of illicit drug use, leading to an overdose within the facility. The lack of communication and documentation regarding the resident's drug history and the absence of a system to address such issues further exemplified the administration's failures. The facility's Quality Assurance Performance Improvement (QAPI) plan was not effectively maintained, and the administration did not ensure that all allegations of abuse and neglect were reported and investigated thoroughly. The governing body failed to provide oversight over the QAPI program, resulting in a lack of timely reporting and investigation of abuse and neglect incidents. The administration's inability to maintain effective communication and oversight contributed to the ongoing Immediate Jeopardy situation, highlighting systemic failures in the facility's management and operations.
Governing Body's Oversight Failure Leads to Immediate Jeopardy
Penalty
Summary
The facility's Governing Body, which includes the Administrator, Senior President of Operations, Regional Director of Operations, Assistant President of Clinical Operations, Regional Nurse Manager, Assistant Director of Nursing, and the Director of Nursing, failed to provide adequate oversight for the Quality Assurance Performance Improvement (QAPI) Program. This failure resulted in the lack of an effective QAPI plan to address, report, and investigate allegations of sexual abuse, physical abuse, and neglect. Additionally, the Governing Body did not implement effective interventions to address the nutritional needs of vulnerable residents, leading to significant weight loss. These deficiencies led to an Immediate Jeopardy situation, indicating that the noncompliance was likely to cause serious harm to residents. The review of the facility's policies and QAPI meeting minutes from June, July, and August 2024 revealed that the facility did not establish or implement interventions to address concerns related to resident abuse, neglect, and nutritional status decline. The facility failed to provide an environment free from abuse and neglect for several residents and did not timely report or thoroughly investigate allegations of abuse and neglect. Furthermore, the facility did not monitor or address residents' nutritional status, resulting in significant weight loss for multiple residents. Interviews with the Administrator and Regional Director of Operations confirmed the Governing Body's responsibility for the QAPI program, yet they were unable to provide documentation showing that the QAPI plan addressed these critical issues.
QAPI Committee's Failure in Addressing Abuse and Nutritional Deficiencies
Penalty
Summary
The Quality Assurance and Performance Improvement (QAPI) Committee at the facility failed to ensure an effective program that systematically identified, reported, tracked, investigated, analyzed, and used data related to abuse and nutritional status. This failure resulted in Immediate Jeopardy when staff did not intervene in multiple incidents of abuse, including a situation where a resident was observed in a compromising position with another resident, and another incident where a resident reported sexual assault by another resident. Additionally, staff failed to intervene when a family member physically abused a resident, and no interventions were implemented for a resident with a history of cocaine abuse, leading to an overdose. The QAPI Committee also failed to address significant and severe weight loss among residents. Several residents experienced substantial weight loss, with meal percentages not being documented consistently. The committee did not identify or monitor systemic failures related to nutrition, which contributed to the weight loss. The facility's documentation was inadequate, with missing QAPI meeting minutes and sign-in sheets, and there was no evidence of root cause analyses being conducted for the incidents. The facility's administration, including the Administrator and Director of Nursing, did not provide adequate oversight for the QAPI program. There was a lack of documentation and follow-up on significant events, and the facility was unable to demonstrate that QAPI meetings were conducted regularly. The Governing Body also failed to ensure the QAPI program was effectively implemented to address and investigate allegations of abuse and neglect, as well as nutritional needs, resulting in significant deficiencies in the quality of care provided to residents.
Failure to Timely Report Abuse and Neglect
Penalty
Summary
The facility failed to timely report allegations of abuse and neglect for several residents, resulting in an Immediate Jeopardy situation. Resident #2 reported an alleged sexual assault by Resident #3, which was not reported to the State Survey Agency within the required 2-hour timeframe. The incident occurred on the night of 5/8/2024, but the report was not made until the following morning. The facility's staff, including a Registered Nurse, failed to act on the allegation immediately, with the nurse dismissing the resident's claims as fabrications. This inaction allowed Resident #3, who was cognitively impaired and known to wander, to continue roaming the facility naked, posing a risk to other residents. In another incident, Resident #19 experienced a cocaine overdose on 11/8/2023, which was not reported to the State Survey Agency within the mandated 2-hour period. The resident was found unresponsive after a visit from an unidentified individual and was treated with Narcan before being transported to the hospital. The overdose was only reported the following day, despite the facility's policy requiring immediate reporting of such incidents. The delay in reporting was acknowledged by the facility's Administrator and Director of Nursing, who confirmed the failure to adhere to the reporting timeline. Additionally, the facility failed to report an allegation of sexual abuse involving Residents #4 and #5 within the required timeframe. The incident was reported to the State Agency over three hours after it occurred, exceeding the 2-hour limit. The Administrator, who was responsible for reporting abuse allegations, admitted to the delay in reporting. These failures to report timely and adequately resulted in a citation for substandard quality of care and highlighted significant lapses in the facility's adherence to its abuse reporting policies.
Inadequate Investigations into Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of abuse and neglect involving several residents. In one instance, a cognitively impaired resident with dementia was allegedly involved in a sexual abuse incident with another resident. The facility's investigation was inadequate as it did not include all relevant witness statements or consider the police report, which contained additional allegations of prior sexual contact between the residents. The facility concluded there was no evidence of sexual abuse, despite conflicting accounts and evidence suggesting otherwise. Another incident involved a resident who alleged sexual assault by another resident, resulting in psychosocial harm and delayed incontinence care. The facility's investigation was insufficient, as it did not thoroughly explore the allegations or gather necessary evidence, such as the soiled sheet used by the alleged perpetrator. The facility also failed to retain video surveillance footage that could have provided crucial information about the incident. Staff interviews were conducted, but the investigation lacked comprehensive documentation and failed to address why the victim was left in a soiled state for an extended period. Additionally, the facility did not adequately investigate a resident's cocaine overdose, which was part of the broader pattern of insufficient investigations. The facility's failure to perform thorough investigations and take appropriate corrective actions resulted in an Immediate Jeopardy situation, posing a risk of serious harm to the residents involved. The facility's policies on abuse prevention and investigation were not effectively implemented, leading to substandard quality of care.
Systemic Failures in Nutritional Care Lead to Significant Weight Loss
Penalty
Summary
The facility failed to adequately assess and address the nutritional needs of several residents, leading to significant and severe weight loss. The report highlights systemic failures in monitoring and documenting meal intake, as well as providing necessary assistance during meals. For instance, Resident #67 experienced a 9% weight loss over two months, with more than half of their meal intakes undocumented. Similarly, Resident #65 lost 8.5% of their body weight in one month, with a significant portion of meal intakes not recorded, and was observed struggling to eat without assistance. Resident #63 suffered a 10.19% weight loss over 3.5 months, with a high percentage of meal intakes undocumented. The facility's failure to follow care plans and document meal consumption contributed to this decline. Resident #45 experienced a 5% weight loss over 1.6 months, with a history of dehydration and missed meals due to inadequate assistance. Interviews with staff and family members revealed a lack of awareness and communication regarding residents' needs for meal assistance and documentation. Resident #46 lost 13.5% of their body weight over 1.5 months, with a significant number of meals undocumented. The facility did not hold an interdisciplinary team meeting to address the weight loss or implement interventions. Observations and interviews indicated that residents were not consistently offered assistance or alternatives during meals, and staff were not adequately informed about residents' dietary needs. These failures resulted in Immediate Jeopardy, as the facility's noncompliance posed a risk of serious harm to the residents.
Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to ensure a safe and secure environment for a vulnerable and high-risk resident with wandering behaviors, leading to an Immediate Jeopardy situation. The resident, who had a history of elopement and was identified as an elopement risk, managed to exit the facility through a window in his room. The resident was found by his sister approximately 3 miles away from the facility, after being missing for about 8 and a half hours. The facility staff were unaware of the resident's absence during this time. The resident had been admitted with multiple diagnoses, including dementia, schizoaffective disorder, and a history of elopement. Despite having a wander guard bracelet and a care plan addressing his elopement risk, the resident was able to leave the facility unnoticed. Interviews with staff revealed that rounds were not conducted as required, and the resident's room was not properly monitored. Additionally, the resident's name was not placed outside his room, leading to confusion among staff about his presence in the facility. The facility's policy on elopement and wandering patients was not effectively implemented, as evidenced by the lack of adequate supervision and monitoring of the resident. Staff interviews indicated that rounds were supposed to be conducted every two hours, but this was not consistently done. The resident's habit of sleeping in the bathroom on the floor was not documented in his care plan, which contributed to the oversight. The facility's failure to monitor the resident and secure the environment resulted in the resident's unauthorized exit and subsequent Immediate Jeopardy citation.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property, specifically involving the narcotic medication Hydrocodone. The facility's policy on abuse prohibition and narcotic control was not adhered to, as evidenced by the missing medication that was not accounted for. The investigation summary revealed that the medication was delivered but could not be found, and there was a lack of documentation regarding the removal of a narcotic card from the cart. The facility's investigation was incomplete, and there was insufficient evidence to determine how the narcotic card was not accounted for. The resident involved, who was admitted with diagnoses including cerebrovascular disease, hemiplegia, and chronic pain, had a physician's order for Lortab, a narcotic pain medication, to be administered three times a day. However, the Medication Administration Record (MAR) showed that the medication was not documented as administered on specific dates. Additionally, the Controlled Drug Receipt/Record/Disposition Form indicated that a nurse signed out the medication but did not document its administration, leading to a discrepancy that was not resolved. The investigation noted that all nurses were drug tested except for an agency nurse who refused to return to the facility for testing. This nurse, who was on duty during the time of the discrepancy, did not work at the facility following the incident. The facility's Director of Nursing confirmed that the investigation did not determine who was responsible for the misappropriation, and there was uncertainty about whether the staffing agency was notified of the nurse's refusal to undergo a drug screen.
Inadequate Transfer Documentation and Communication
Penalty
Summary
The facility failed to ensure proper documentation and communication during the transfer or discharge of residents, as evidenced by the lack of completed transfer forms and physician orders for six residents. The facility's policy requires that a Transfer to Hospital Form be completed and sent with the resident, including details such as current diagnosis, medications, and contact information. However, for all six residents reviewed, these forms were either incomplete or not sent, and physician orders for transfers were not consistently documented. Resident #44, for instance, was transferred to the hospital without a completed transfer form, and the family was not notified of the transfer. The clinical notes indicated that the resident exhibited severe behavioral disturbances, leading to the decision to transfer him for a psychological evaluation. Despite the urgency, the necessary documentation was not completed, and the family member reported not being informed about the transfer, highlighting a communication breakdown. Similarly, other residents, such as Resident #43 and Resident #52, were transferred without documented physician orders or completed transfer forms. In some cases, the receiving hospitals were not informed of the residents' medical conditions or the reasons for their transfers, as seen with Resident #52, who was disoriented upon arrival at the emergency department. The facility's failure to adhere to its transfer and discharge policy resulted in inadequate communication and documentation, compromising the safe and effective transition of care for these residents.
Failure to Provide Bed-Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to provide a bed-hold notice to residents or their representatives at the time of transfer to a hospital or therapeutic leave for five out of six residents reviewed for discharge. The facility's policy, revised on 7/31/2023, mandates that written information regarding bed-hold policies be provided to residents and/or their representatives prior to transferring a resident. However, this policy was not adhered to in the cases reviewed. Resident #43, who was admitted with diagnoses including unspecified dementia and chronic kidney disease, was transferred twice to a psychiatric hospital without documentation of a bed-hold form. The resident's Power of Attorney confirmed that no bed-hold policy was communicated during these transfers. Similarly, Resident #52, admitted with acute kidney failure, was transferred to a hospital for a blood transfusion without a bed-hold form being initiated. The Director of Nursing (DON) acknowledged the absence of documentation for these transfers. Additional cases include Resident #53, who was transferred due to worsening health conditions, Resident #54, who was sent to the ER for further evaluation after being found lethargic, and Resident #51, who was transferred to a hospital for evaluation after a decline in condition. In each instance, the medical records lacked documentation of a bed-hold form, and the DON confirmed the facility's failure to provide the required bed-hold policy to residents or their representatives at the time of transfer.
Failure to Update Care Plans for Residents with Head Lice
Penalty
Summary
The facility failed to update the care plans for two residents who were found to have head lice, which required isolation precautions. Resident #45, diagnosed with Alzheimer's disease, Nutritional Deficiency, and GERD, was noted to have a roommate with lice, and a lice-killing shampoo was ordered. However, the care plan for Resident #45 did not include any interventions for the lice condition or isolation precautions. Similarly, Resident #56, with diagnoses including Sepsis, Acute Respiratory Failure, and Encephalopathy, was observed to have lice during a shower, and a lice-killing shampoo was ordered. Despite this, the care plan for Resident #56 also lacked any mention of the lice condition or necessary isolation precautions. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the care plans for both residents were not updated to reflect the need for isolation precautions due to head lice. The MDS Coordinator acknowledged the absence of care plans for the lice condition, and the Director of Nursing stated that residents with head lice should be placed on contact isolation and that their care plans should reflect this. The failure to update the care plans for these residents represents a deficiency in the facility's adherence to its policy of developing comprehensive, person-centered care plans.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary services for maintaining personal hygiene for a resident who was unable to perform activities of daily living (ADL) independently. The facility's policy required that care and services be provided for activities such as bathing, dressing, and grooming. However, the review of the ADL Verification Worksheets revealed that the resident received significantly fewer bed baths than scheduled and did not receive any showers over several months. The resident was dependent on staff for personal hygiene and transfers, as indicated in the medical records and care plan. Interviews with family members and staff highlighted the deficiency in care. A family member reported that the resident smelled sour and did not receive proper nail care or showers. The Director of Nursing confirmed that the resident's ADL documentation was incomplete and that the facility had the capability to shower residents with tracheostomies. A CNA reported that due to staffing issues and heavy workloads, residents often did not receive their baths, especially on weekends, and that there was a high turnover of staff due to the demanding conditions.
Failure to Document Physician Orders for Medication Administration
Penalty
Summary
The facility failed to provide a physician order for medication administration for two residents, leading to a deficiency in following proper procedures for medication orders. Resident #43, who was admitted with diagnoses including Unspecified Dementia, Type 2 Diabetes, Anxiety Disorder, and Chronic Kidney Disease, was administered Haldol 5mg IM after becoming combative. However, there was no documented physician order for this medication in the resident's medical record for February 2024. The Director of Nursing acknowledged the absence of the order during a review of the medical record. Similarly, Resident #8, admitted with conditions such as Atrial Fibrillation, Hemiplegia, and Altered Mental Status, was given simethicone following a verbal order from a Nurse Practitioner after the resident began vomiting. The Physician Order Sheet for September 2024 did not contain an order for simethicone. The Assistant Director of Nursing confirmed that all medications administered must have a corresponding doctor's order, and the Director of Nursing acknowledged the lack of documentation for the simethicone order. These incidents highlight the facility's failure to adhere to its policies regarding verbal and telephone orders, as well as medication administration.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to the development and progression of pressure ulcers. Resident #31, who was admitted with conditions including Acute Diastolic Heart Failure, Morbid Obesity, and Protein Calorie Malnutrition, developed a facility-acquired Stage IV pressure ulcer on the coccyx. The resident's care plan indicated a risk for impaired skin integrity and required weekly skin audits, but the ulcer was not discovered until it had progressed to Stage IV. The Wound Care Nurse acknowledged that the wound should have been identified before reaching such an advanced stage, suggesting that weekly skin audits were not effectively conducted. Interviews with facility staff revealed a lack of adherence to established protocols for skin assessments. The Director of Nursing stated that her expectations were for nursing staff to complete full body skin audits weekly and for CNAs to perform skin checks during showers. However, the process for identifying and reporting new or worsening skin conditions was not followed, as evidenced by the failure to detect the pressure ulcer in a timely manner. This deficiency highlights a breakdown in communication and protocol adherence among the nursing staff, leading to inadequate wound care and prevention measures for the residents involved.
Inadequate Staffing and RN Coverage
Penalty
Summary
The facility failed to maintain sufficient nursing staff to ensure resident safety and well-being, as evidenced by a review of the facility assessment, employee time sheets, and interviews. The facility assessment indicated a staffing plan based on resident needs, but the actual staffing levels were inadequate, particularly on weekends and nights. The review of employee time sheets revealed that the facility relied heavily on agency staff, with 81 different agency staff working from April to June 2024. On several occasions, the facility did not meet the required 8 hours of RN coverage, and the Per Patient Day (PPD) staffing hours were consistently low, indicating insufficient staffing to meet resident needs. Interviews with staff and residents highlighted the impact of inadequate staffing. A CNA reported being understaffed and having to care for 18 residents alone, leading to dissatisfaction and eventual resignation. The Ombudsman noted resident complaints about unmet needs, such as not being changed and unanswered call lights. The Administrator acknowledged the staffing issues, citing a high reliance on agency staff and a lack of consistent staffing management. The Activities Director, who was temporarily handling staffing, admitted to not attending Quality Assurance Performance Improvement meetings and being unfamiliar with the Payroll Based Journal (PBJ) requirements. The facility's staffing challenges were compounded by high turnover and a lack of permanent staff in key positions. The Activities Director mentioned open positions for Unit Managers, charge nurses, and CNAs, indicating a significant staffing gap. Interviews with former staff members revealed that the heavy workload and inadequate support contributed to the high turnover. The Administrator and other staff members acknowledged the ongoing staffing difficulties, with staffing being managed by a patchwork of different managers and lacking a dedicated staffing coordinator.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, as required by federal regulations. Specifically, on two days in June 2024, the facility did not have the mandated RN coverage. This deficiency was identified through a review of the facility's assessment, nursing home licensure checklist, and employee time sheets, which confirmed the absence of RN coverage for the required duration on June 15 and June 23, 2024. During an interview, the Administrator acknowledged the staffing shortage and the lack of RN presence on those days.
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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