Green Hills Center For Rehabilitation And Healing
Inspection history, citations, penalties and survey trends for this long-term care facility in Nashville, Tennessee.
- Location
- 3939 Hillsboro Circle, Nashville, Tennessee 37215
- CMS Provider Number
- 445267
- Inspections on file
- 19
- Latest survey
- February 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Green Hills Center For Rehabilitation And Healing during CMS and state inspections, most recent first.
The facility failed to maintain sanitary conditions in its food service department, with kitchen equipment found with buildups of unknown substances and improper food storage practices. Staff did not adhere to hygiene protocols, such as covering hair and performing hand hygiene. These deficiencies were confirmed by the Regional Food and Nutrition Director, highlighting a lack of adherence to facility policies.
The facility failed to maintain resident dignity during meal assistance, as staff members were observed standing over residents while assisting them with meals. This included residents with severe cognitive impairment and those who were cognitively intact but physically dependent. The Director of Nursing confirmed that staff should not stand over residents, indicating a breach of protocol.
The facility failed to maintain the confidentiality of residents' medical records, as observed during random checks. LPNs left computer screens open and unattended, displaying residents' names and room numbers. The Director of Nursing confirmed that this practice was against facility policy.
The facility failed to conduct quarterly care plan meetings for five residents, as required by their policy. Despite the residents' varying cognitive statuses, the facility did not document these meetings, indicating a lapse in adherence to their comprehensive person-centered care plan policy. The DON confirmed the requirement for quarterly meetings, underscoring the facility's non-compliance.
The facility failed to provide adequate ADL care and hygiene for three residents, resulting in deficiencies in personal hygiene and grooming. A resident with moderate cognitive impairment did not receive a shower for several weeks, while another resident's toenails were unkempt despite a physician's order for podiatry services. A third resident, severely cognitively impaired, did not receive scheduled showers, and their hair was observed to be unkempt. Staff interviews confirmed these deficiencies.
A high-risk resident with cerebral infarction and hemiplegia developed a stage 4 pressure ulcer on the left ear due to inadequate care and delayed interventions. The facility failed to document the injury promptly, lacked physician's orders for treatment, and delayed nutritional interventions. Observations showed the resident often lying on the affected side without a wound dressing, and the DON confirmed the injury was not addressed immediately.
A facility failed to ensure the safety of a resident with a history of substance use disorder, who frequently left against medical advice (AMA) and returned intoxicated. The resident, using a motorized wheelchair, navigated unsafe areas and consumed alcohol and delta-8 THC gummies. The facility lacked documentation of monitoring and education provided to the resident, and AMA forms were incomplete. Interviews revealed no systematic approach to ensure the resident's safety, despite acknowledgment of the facility's responsibility.
A resident with severe cognitive impairment returned to the facility with an indwelling urinary catheter, but the facility failed to obtain a physician's order and update the care plan until during the survey. Additionally, a CNA did not perform proper hand hygiene during catheter care, as confirmed by the DON.
The facility failed to properly store medications, with issues including mixing internal and external medications, storing toxic chemicals with medications, and leaving medication carts unsecured. LPNs and RNs confirmed these practices were inappropriate, and a discontinued medication was improperly stored in the medication room.
The facility failed to follow infection control practices, as two staff members did not properly store soiled linens and failed to wear PPE for Enhanced Barrier Precautions. Additionally, an LPN did not disinfect reusable medical equipment after use. The DON confirmed these actions were against the facility's policies.
The facility failed to protect a resident from neglect, resulting in a fall and hip fracture due to inadequate assistance during incontinence care. Additionally, two residents experienced verbal abuse from a CNA, causing psychosocial harm. The facility's policies on fall management, MDS assessment, and abuse prevention were not adequately followed, leading to delayed treatment and compromised care.
A resident with severe cognitive impairment and a need for extensive assistance fell from bed during incontinence care, resulting in a hip fracture. The care plan lacked specific safety interventions for the use of an air mattress and the resident's seizure diagnosis, leading to the incident.
A resident at high risk for falls and requiring extensive assistance with ADLs fell from bed and sustained a left hip fracture during incontinence care performed by a single CNA, despite the care plan indicating a need for a two-person assist. The facility's policies on fall management, MDS assessment, and care planning were not adequately followed, and the incident revealed inconsistencies in staff accounts and inadequate documentation and assessment of the resident's condition post-fall.
The facility failed to provide effective pain management for two residents due to delays in administering scheduled pain medications. An agency nurse was unable to log into the computer system on time, resulting in increased pain and harm for the residents. One resident with a femur fracture experienced severe pain and was unable to complete physical therapy, while another resident with multiple diagnoses, including cancer, reported severe pain due to delayed medication administration.
The facility failed to provide adequate grooming, incontinence care, timely call light response, and personal hygiene for six residents. Residents reported waiting for hours for assistance, being left in soiled conditions, and not receiving regular showers or baths. Observations confirmed poor hygiene and neglect, with residents found in dirty clothing and bedding. Interviews with staff and family members corroborated these findings, highlighting a lack of adherence to care plans and facility policies.
A resident with no cognitive impairment was inappropriately fitted with a wanderguard bracelet after going to a fenced courtyard, leading her to feel like she was in jail. The staff's actions did not align with the facility's policies on wandering and elopement, and the resident's complaints were not adequately addressed.
The facility failed to report allegations of verbal abuse and neglect to the state agency within the required 2-hour timeframe for three residents. The incidents involved verbal abuse and neglect by a CNA, and the delays in reporting ranged from 15 to 18 hours. Interviews with residents and staff confirmed the abuse and the reporting delays.
The facility failed to thoroughly investigate allegations of verbal abuse and neglect involving three residents. One resident reported not receiving a shower and being rudely treated by a CNA, while another resident and their roommate reported a confrontation with a CNA who made threatening remarks. The facility's investigations were incomplete, and the administrator did not interview all relevant staff or take immediate action to protect the residents.
The facility failed to communicate critical information about a resident's fall during their transfer to a hospital for neurological evaluation. The omission in both oral and written reports could have likely resulted in a delay of treatment.
The facility failed to administer medications as ordered for three residents. One resident missed 14 medications due to staffing issues, another did not receive Dupixent injections because the medication was unavailable, and a third missed 22 doses of IV Cefepime due to a reconstitution error and failure to reorder the medication.
The facility failed to identify and correct quality deficiencies when a resident exited the building unnoticed for 7.5 hours and another resident fell from bed during care, resulting in a left hip fracture. The facility did not follow its QAPI policy, and no root cause analysis or corrective actions were taken for these incidents.
A resident exited the building twice unnoticed on the same day due to inadequate supervision and failure to follow facility policies. Despite being brought back inside after the first incident, no new interventions were implemented, leading to the resident's second unsupervised exit. The facility's lack of investigation and staff training resulted in Immediate Jeopardy.
Sanitation and Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to maintain sanitary conditions in its food service department, as evidenced by multiple observations of unsanitary practices and conditions. Kitchen equipment, including the cooking stove, deep fryer, griddle, and ovens, were found with thick black and brown buildups of unknown substances. The ice machine had rusted screws, black buildup, and a pink substance, which was confirmed to be mold by the Maintenance Director. Additionally, food items were improperly stored, with many being opened, undated, and expired, including various meats, vegetables, and dairy products. Staff members were observed not adhering to hygiene protocols, such as failing to cover hair and facial hair, and not performing hand hygiene before and after glove use. Specific instances included dietary aides and chefs working without hairnets or facial hair coverings, and failing to wash hands after removing gloves or before food preparation. These lapses in hygiene practices were confirmed by the Regional Food and Nutrition Director, who acknowledged the necessity of these measures to prevent contamination. The facility's policies on food storage, sanitation, and hand hygiene were not followed, leading to the observed deficiencies. Food was left uncovered and unattended, and clean dishes were placed on soiled carts. The Regional Food and Nutrition Director confirmed that these practices were against the facility's policies, which require food to be covered when unattended and carts to be cleaned before use. The lack of adherence to these policies contributed to the unsanitary conditions observed during the survey.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect during meal assistance, as observed in multiple instances involving staff members. Certified Nursing Assistants (CNAs) K, L, M, and N, along with an MDS Nurse, were seen standing over residents while assisting them with meals. This action is contrary to the facility's Resident Rights document, which mandates that employees treat all residents with kindness, respect, and dignity. The Director of Nursing confirmed that staff should not stand over residents during meal assistance, indicating a breach of protocol. The report highlights specific cases involving five residents with varying degrees of cognitive impairment and physical dependency. Residents with severe cognitive impairment, such as those with Alzheimer's Disease, and those who are cognitively intact but physically dependent, were all subjected to this undignified treatment. Observations were made on different dates, showing a pattern of behavior that disregards the residents' rights to a dignified existence and self-determination, as outlined in the facility's policies.
Failure to Maintain Resident Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' medical records for 27 out of 119 residents during a random observation and medication administration. The facility's policy on Resident Rights, dated February 2011, mandates that employees treat all residents with kindness, respect, and dignity, including ensuring privacy and confidentiality. However, during an observation on the 200 Hall, a Licensed Practical Nurse (LPN) was found sitting away from the medication cart with the computer screen left open and unattended, displaying residents' names and room numbers. The LPN acknowledged that the screen should not be left open when unattended. Further observations on the 300 Hall revealed similar issues with another LPN leaving the computer screen open and unattended while entering residents' rooms. This resulted in the exposure of residents' names and room numbers. During an interview, the Director of Nursing confirmed that computer screens should not be left unattended with residents' information visible. These incidents demonstrate a failure to adhere to the facility's policy on maintaining the confidentiality of residents' medical records.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct quarterly care conference meetings for five residents, as required by their policy on comprehensive person-centered care plans. The policy mandates that each resident's care plan be developed and revised with their participation, and that care planning conferences be held quarterly. However, the facility did not provide documentation of these meetings for the residents in question, indicating a lapse in adherence to their own policy. Resident #9, with mild cognitive impairment, had no documented care plan meetings since June 2024. Resident #10, who had no cognitive impairment, last had a care plan meeting in March 2024. Resident #25, also cognitively intact, had a significant gap between meetings from June 2024 to February 2025. Resident #36, with no cognitive impairment, had a similar gap from July to December 2024. Lastly, Resident #39, who was cognitively intact, had no documented meetings after June 2024. The Director of Nursing confirmed the requirement for quarterly meetings, highlighting the facility's failure to comply with this standard.
Deficiencies in ADL Care and Hygiene for Residents
Penalty
Summary
The facility failed to provide adequate care and services related to activities of daily living (ADLs) for three residents, resulting in deficiencies in maintaining personal hygiene and grooming. Resident #5, who has moderate cognitive impairment and requires assistance with all ADLs, did not receive a shower or bath after January 7, 2025, as documented in the facility's records. The facility was unable to provide evidence that Resident #5 received the necessary hygiene care for the remainder of January 2025. Resident #9, with moderate cognitive impairment and requiring maximal assistance with bathing, was observed with long, thick, and unkempt toenails, indicating a lack of grooming and podiatric care. Despite a physician's order for podiatry services, the resident's toenails were not attended to, as confirmed by the Unit Manager. Resident #317, who is severely cognitively impaired and dependent on staff for ADLs, was scheduled for showers twice a week but had not received a shower since January 17, 2025. Observations revealed that Resident #317's hair was unkempt and uncombed, and interviews with staff confirmed the resident had not received the scheduled showers or daily grooming.
Failure to Prevent and Manage Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide adequate care and services for the prevention of pressure ulcers for a resident identified as high risk. The resident, who was admitted with diagnoses including cerebral infarction, hemiplegia, and muscle weakness, was found to have a stage 4 pressure injury on the left ear. The facility's policies on pressure ulcer prevention and care were not followed, as evidenced by the lack of documentation and timely intervention for the pressure injury. The resident's care plan indicated a high risk for pressure injury development, with a Braden Scale score of 12, categorizing them as high risk. Despite this, the facility did not document the pressure injury in the medical record on the date it was identified, nor were there any physician's orders for treatment or documentation of the injury's appearance and size. Observations revealed that the resident was often found lying on the left side without a wound dressing, and nutritional interventions were delayed. Interviews with the Director of Nursing confirmed that the pressure injury was observed on a specific date, but interventions were not immediately implemented. The DON acknowledged that the resident's positioning likely contributed to the development of the pressure injury and that a wound dressing should have been intact. The failure to document and address the pressure injury promptly, along with the lack of immediate nutritional interventions, highlights the facility's deficiency in providing necessary care to prevent and manage pressure ulcers.
Facility Fails to Ensure Safety of Resident with Substance Use Disorder
Penalty
Summary
The facility failed to ensure a safe and secure environment for a resident with a history of substance use disorder, leading to multiple incidents of the resident leaving the facility against medical advice (AMA) and returning intoxicated. The resident, who had a BIMS score indicating no cognitive impairment, was known to leave the facility to consume alcohol and delta-8 THC gummies, posing significant safety risks. Despite the facility's policy on substance use disorder, there was a lack of documentation and monitoring of the resident's condition upon returning from these excursions. The resident was observed leaving the facility in a motorized wheelchair, navigating unsafe areas such as a sloped driveway leading to a busy street. The facility's staff failed to document the times the resident left and returned, as well as the education provided to the resident about the risks of leaving AMA. Additionally, there was no evidence of the required 15-minute monitoring checks after the resident returned intoxicated, as ordered by the nurse practitioner. Interviews with facility staff, including the administrator, revealed a lack of a systematic approach to ensure the resident's safety while out AMA. The AMA forms were incomplete, missing critical information such as the responsible physician's signature, times, and witness signatures. The administrator acknowledged the facility's responsibility for the resident's safety but was unable to provide a concrete plan to address the ongoing safety concerns.
Deficiency in Catheter Care and Hand Hygiene
Penalty
Summary
The facility failed to provide appropriate services and treatment for an indwelling urinary catheter for a resident who was admitted with a catheter but did not have a physician's order for its use until during the survey. The resident, who had severe cognitive impairment and a history of a cerebral vascular accident, dysphagia, and a PEG tube, returned to the facility with the catheter, but the care plan was not updated to reflect this until the survey. Observations confirmed the presence of the catheter, and interviews with staff, including an LPN and the Director of Nursing, acknowledged the oversight in obtaining the necessary order and updating the care plan. Additionally, a CNA failed to perform proper hand hygiene during catheter care for the resident. After providing incontinent stool care, the CNA removed gloves but did not perform hand hygiene before donning a new pair of gloves to continue with catheter care. This failure to adhere to hand hygiene protocols was confirmed by the Director of Nursing, who emphasized the importance of hand hygiene in preventing healthcare-associated infections.
Improper Medication Storage and Management
Penalty
Summary
The facility failed to ensure proper storage of medications in several areas, leading to deficiencies in medication management. On the 200 Hall Medication Cart #1, disinfectant wipes were stored with heparin lock flushes without a separation barrier, and various oral medications were stored together with skin irritation treatments in a plastic container without a barrier. Additionally, a box of pain relief gel packets was found opened and undated. These storage practices were confirmed as inappropriate by LPN R, who acknowledged that internal and external medications should not be stored together, nor should toxic chemicals be stored with medications. On the 100 Hall Medication Cart #1, scopolamine patches were stored without a barrier alongside insulin injection pens and ondansetron injection. A bottle of liquid protein oral supplement was found opened and undated, and oral suspension medication was stored with various nasal sprays without separation. RN HH confirmed these storage practices were incorrect, emphasizing the need for separation and proper labeling. Furthermore, the 300 Hall Medication Cart #2 was left unsecured and out of sight by LPN O, which was acknowledged as inappropriate by the DON. In the 300 Hall Medication Room, a discontinued medication was improperly stored, which LPN Q confirmed should have been returned to the pharmacy or discarded.
Infection Control Deficiencies in PPE Use and Equipment Disinfection
Penalty
Summary
The facility failed to adhere to proper infection control practices as outlined by the CDC guidelines and the facility's own policies. Two staff members, a CNA and an LPN, did not properly store soiled linens and failed to wear appropriate PPE for Enhanced Barrier Precautions (EBP). Specifically, soiled linens were observed on the floor in the rooms of two residents, one of whom had a wound requiring EBP. The CNA admitted to placing the soiled linen on the floor, and the LPN was observed kicking the linen behind a door and later removing it without donning the required PPE. Additionally, the LPN failed to disinfect reusable medical equipment after use. In one instance, the LPN used a blood pressure machine and pulse oximeter on a resident and then placed the equipment back into the medication cart without cleaning or disinfecting it. The Director of Nursing confirmed that these actions were against the facility's infection control policies, which require the disinfection of reusable equipment and the use of gowns and gloves in rooms where EBP is necessary.
Neglect and Verbal Abuse in LTC Facility
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in actual harm. Resident #319, who had severe cognitive impairment, contractures, and hemiparesis, required two-person assistance for bed mobility and incontinence care. However, staff provided only one-person assistance, leading to the resident falling from the bed and sustaining a left hip fracture. The facility also failed to monitor the resident for adverse outcomes related to the fall, resulting in a delay of treatment for one day. Additionally, the facility did not report the fall to the receiving emergency department, compromising the safe transition of care. The facility's policies on fall management, MDS assessment, and abuse prevention were not adequately followed. The care plan for Resident #319 lacked focus and interventions for seizure diagnosis and behaviors associated with jerking motions or spasms during care. The air mattress safety interventions were also not included in the care plan. The staff involved in the incident, including the CNA and LPN, did not receive proper training on ADL care for residents on an air mattress, and there was a lack of documentation and follow-up assessment after the fall. In another incident, the facility failed to protect two residents from verbal abuse by a CNA. The CNA made verbal threats and derogatory statements to the residents, causing psychosocial harm. The facility's investigation into the abuse was delayed, and the CNA continued to work the remainder of the shift after the incident. The facility's policies on abuse prevention and reporting were not adequately implemented, leading to a failure to protect the residents from further harm.
Failure to Implement Person-Centered Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for Resident #319, who had severe cognitive impairment and required extensive assistance with bed mobility and transfers. Despite the resident's need for a two-person assist for bed mobility, the care plan did not include specific safety interventions for the use of an air mattress or for the resident's seizure diagnosis and associated jerking motions during care. This oversight led to an incident where the resident fell from the bed during incontinence care, resulting in a left hip fracture. The incident occurred when a CNA was providing incontinence care to Resident #319, who was lying on his side on an air mattress. The resident exhibited jerking movements and forcefully projected himself off the bed. The CNA attempted to catch the resident but was unsuccessful, leading to the fall. The facility's incident report incorrectly stated that there were no witnesses, although both the CNA and the resident's roommate witnessed the fall. The resident was subsequently taken to the emergency department, where a left hip fracture was confirmed. Interviews with facility staff revealed that the care plan did not adequately address the resident's needs. The CNA involved in the incident stated that the care plan indicated a one-person assist, contrary to the resident's documented need for a two-person assist. Additionally, the facility's former DON and MDS Coordinator acknowledged that the care plan lacked interventions for the resident's seizure diagnosis and the use of an air mattress. The facility's failure to implement the appropriate plan of care and establish necessary safety measures directly contributed to the resident's fall and injury.
Failure to Provide Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to provide a safe environment for Resident #319, who was at high risk for falls and required extensive assistance with activities of daily living (ADLs). Despite the resident's care plan indicating the need for a two-person assist for bed mobility and transfers, incontinence care was performed by a single CNA. During this care, the resident fell from the bed and sustained a left hip fracture. The incident report and subsequent interviews revealed inconsistencies in the accounts of the fall, with the CNA stating that the resident's body tensed and he projected himself off the bed, while the resident later claimed he was pushed. The facility's investigation did not substantiate the resident's claim of being pushed, but it did confirm that the resident fell and was injured during care that did not adhere to the prescribed two-person assist protocol. The facility's policies on fall management, MDS assessment, and care planning were not adequately followed. The resident's care plan lacked specific interventions for his seizure diagnosis and the use of an air mattress, which was identified as a contributing factor to the fall. The CNA involved in the incident had no documented training for ADL care, and the facility failed to provide documentation of any assessments performed related to the fall. Additionally, the facility did not document any continuing assessment for changes in the resident's condition post-fall, and there was no evidence that the resident was provided with appropriate pain management following the incident. Interviews with staff and family members highlighted further deficiencies in the facility's response to the fall. The former DON claimed to have performed a head-to-toe assessment and used a mechanical lift to return the resident to bed, but this was contradicted by other staff members who stated that no lift was used and the DON was not present. The resident's family member had to demand that the resident be sent to the hospital for X-rays, which revealed a left hip fracture. The facility's failure to adhere to care plans, provide adequate supervision, and properly document and assess the resident's condition resulted in actual harm to the resident.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for two residents, resulting in actual harm. Resident #221, who was admitted with a trochanteric fracture of the left femur and Type 2 Diabetes Mellitus, did not receive his scheduled pain medication on time. The delay was caused by an agency nurse's inability to log into the computer system to administer medications. As a result, Resident #221 experienced increased pain and was unable to complete his physical therapy session. The resident was observed grimacing and groaning in pain, and he reported that his pain medication was consistently late, impacting his ability to manage pain effectively. Similarly, Resident #224, who was admitted with multiple diagnoses including unspecified cord compression, malignant neoplasm of the lung and spinal cord, and neoplasm-related pain, also did not receive her scheduled pain medication on time. The delay in administering Morphine Sulfate ER and Methocarbamol resulted in the resident experiencing severe pain, rated as a 9 on a scale of 1-10. The resident's call light was activated to request pain medication, and it was noted that the nurse was behind on her medication pass due to login issues with the computer system. Interviews with staff revealed that the agency nurse, LPN #44, was unable to start her medication pass on time because she did not have the necessary login information for the electronic medical record system. This issue was communicated to the former Director of Nursing (DON), who confirmed that the login information was provided late. Additionally, another LPN confirmed that agency nurses often faced similar challenges, impacting their ability to administer medications promptly. The facility's failure to provide timely login information and support to agency staff directly contributed to the delay in pain management for both residents, resulting in actual harm.
Failure to Provide Adequate Personal Care and Timely Assistance
Penalty
Summary
The facility failed to provide adequate grooming, incontinence care, timely call light response, and personal hygiene for six residents. The facility's policies on answering call lights, bathing, and ADL support were not adhered to, resulting in residents experiencing neglect and poor care. Residents reported waiting for hours for assistance, being left in soiled conditions, and not receiving regular showers or baths as per their care plans. Observations confirmed that residents had dirty fingernails, unkempt hair, and were often found in soiled clothing and bedding. Resident #4, who had no cognitive impairment, reported being left wet for hours and not receiving regular showers. Resident #56, also cognitively intact, had long, dirty fingernails and reported not receiving a shower for weeks, relying on family members for grooming. Resident #81, with a history of heart failure, was found with oily, flaky hair and dirty fingernails, and reported not receiving a bath or shower for months. This resident was later admitted to the hospital for acute heart failure exacerbation, with the hospital noting poor hygiene. Other residents, including Resident #220, Resident #221, and Resident #368, also reported similar issues. Resident #220 received only a few showers and mostly sponge baths, while Resident #221, who was non-weight bearing, had to bear weight to get to the bathroom due to long wait times for assistance. Resident #368 reported not receiving any showers since admission and being left in soiled conditions for hours. Interviews with staff and family members corroborated these findings, highlighting a lack of adherence to care plans and facility policies, resulting in significant neglect and poor quality of care for the residents.
Inappropriate Use of Wanderguard Bracelet on Resident
Penalty
Summary
The facility failed to treat Resident #88 with respect, dignity, and care in a manner that promotes the maintenance and enhancement of her quality of life. Resident #88, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Cirrhosis of the Liver, and Depression, had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Despite this, a wanderguard bracelet was placed on her ankle without documented evidence of wandering, confusion, delirium, or exit-seeking behavior. This action was taken after Resident #88 went to the courtyard, an area she had access to and was fenced, without attempting to leave the facility premises. The resident expressed feeling like she was in jail and complained about the bracelet to multiple staff members, indicating that it made her feel controlled and restricted her ability to go outside for fresh air and activities she enjoyed, such as reading and coloring. The staff's decision to place the bracelet was based on a misunderstanding of her actions and did not align with the facility's policies on wandering and elopement, which require a resident to be at risk of leaving the facility or wandering without purpose. Interviews with various staff members, including LPNs and the Regional Nurse Consultant, revealed inconsistencies in the understanding and application of the facility's policies, further contributing to the inappropriate use of the wanderguard bracelet on Resident #88.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of verbal abuse and neglect to the state agency within the required 2-hour timeframe for three residents. Resident #53, who had no cognitive impairment and required substantial assistance with activities of daily living, was allegedly verbally abused and neglected. The incident was reported by a family member but was not communicated to the state agency until 18 hours later. Resident #53 confirmed the neglect and verbal abuse during an interview. Resident #56, also with no cognitive impairment, reported that a CNA verbally abused her and her roommate late at night. The incident was not reported to the state agency until 15 hours later. Resident #56 expressed fear and distrust towards the CNA, and the incident was corroborated by her roommate and other staff members. The facility's investigation revealed that the night supervisor and other staff were aware of the incident but did not report it promptly. Resident #81, who had no cognitive impairment and required care following a surgical amputation, reported a confrontation with a CNA who used derogatory language and threatened him. The incident was reported to the facility's administrator the next day, and the state agency was notified 15 hours after the incident occurred. Interviews with the residents and staff confirmed the verbal abuse and the delay in reporting. The facility's former DON acknowledged that the allegations should have been reported within 2 hours but were not.
Failure to Investigate Allegations of Verbal Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of verbal abuse and neglect involving three residents. One resident reported not receiving a shower for several days and being rudely treated by a CNA. The facility's investigation did not document the resident's refusal of care or include a care plan addressing such refusals. The former DON admitted to not questioning other residents or investigating the reasons behind the refusals, leading to an incomplete investigation. Another incident involved a resident who reported a confrontation with a CNA, who allegedly made threatening and derogatory remarks. The resident's roommate corroborated the allegations. Despite the severity of the claims, the facility's investigation was incomplete, as the administrator did not interview all relevant staff or the roommate. The administrator acknowledged the failure to conduct a thorough investigation and take immediate action to mitigate the risk of harm to the residents. The facility's investigation into the second incident revealed conflicting statements between the resident and the CNA. However, the administrator did not follow up on documented findings or interview all involved parties, resulting in an incomplete investigation. The residents involved expressed fear and anxiety due to the CNA's behavior, and the facility failed to protect them from further harm during the investigation.
Failure to Communicate Critical Information During Resident Transfer
Penalty
Summary
The facility failed to communicate appropriate information to the receiving facility during the transfer of a resident. Resident #319, who had severe cognitive impairment and a history of neurological issues, was transferred to a hospital for evaluation of neurological symptoms. However, the facility's nursing staff did not include information about a fall that the resident had experienced the previous day in both the oral and written reports to the hospital. This omission was confirmed during an interview with an LPN who stated that if he had known about the fall, he would have included it in the transfer form and report call. The facility's policy on transfer and discharge procedures requires that all necessary information be communicated to ensure a safe and effective transition of care. Despite this, the transfer form completed by the former DON and the report called in by the LPN did not mention the fall. The facility was also unable to provide an updated policy on transfer and discharge procedures. This failure to communicate critical information could have likely resulted in a delay of treatment for the resident at the emergency department.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered by the physician for three residents. Resident #321, who was admitted with multiple diagnoses including Multiple Sclerosis and fractures, did not receive 14 medications as ordered on a specific date. The Medication Administration Record (MAR) showed missing 6:00 AM medications, and there was no documentation explaining why the medications were not administered. Interviews revealed that the night shift nurse was unable to administer all medications due to being the only nurse on duty, and the subsequent nurse could not complete the remaining medications due to time constraints. Resident #370, admitted with diagnoses including Cellulitis and Methicillin Resistant Staphylococcus Aureus Infection, did not receive the Dupixent injection on two occasions because the medication was not available. The nurse failed to follow up with the pharmacy or clinician to ensure the medication was obtained. The Director of Nursing stated that it is unacceptable for a resident to miss a medication and expected the nurse to notify the pharmacy or clinician if an ordered medication is not available. Resident #372, admitted with diagnoses including infection and inflammatory reaction due to an unspecified internal joint prosthesis, missed 22 consecutive doses of the IV antibiotic Cefepime for sepsis. The issue arose when the medication was reconstituted with normal saline instead of glucose, and the Nurse Practitioner failed to reorder the medication. Interviews with the nursing staff and the Medical Director confirmed that the medication was not administered for eight days, and the Nurse Practitioner acknowledged the mistake.
Failure to Identify and Correct Quality Deficiencies
Penalty
Summary
The facility failed to identify and correct quality deficiencies when a resident exited the building in his wheelchair and remained unnoticed for 7.5 hours. The facility's policy on QAPI was not followed, as there was no root cause analysis or corrective action taken regarding staff supervision at the exit door. The Administrator admitted to not considering an in-service related to the front door or seeing the exit door as a problem, and no QAPI meeting was conducted to address the incident. The Medical Director also confirmed that he was not involved in a root cause analysis for this event. Additionally, the facility failed to document and address a fall incident where a resident fell from bed during incontinence care and sustained a left hip fracture. The QAPI meeting notes from June did not include any documentation of the fall that occurred in May. The Administrator could not explain why the incident was not documented. This failure to prevent an avoidable accident resulted in a major injury to the resident.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide an environment free from accident hazards and adequate supervision for Resident #106, who exited the building twice unnoticed on the same day. The first incident occurred when a staff member unlocked the front door for a visitor, allowing Resident #106 to follow the visitor out at 12:31 PM. Despite the Interim Director of Nursing and the Administrator noticing and bringing Resident #106 back inside, no new interventions were put in place. Resident #106 exited the building again at approximately 1:35 PM when another staff member unlocked the front door for a visitor, and he was not noticed missing until approximately 9:00 PM, 7 1/2 hours later. The facility's failure to investigate and determine the root cause of the first incident, as well as the lack of immediate corrective actions, contributed to Resident #106's second unsupervised exit. The facility's policies on accidents, incidents, and elopements were not followed, and staff members were not adequately trained or informed about monitoring the exit door. Interviews with various staff members revealed a lack of awareness and communication regarding Resident #106's risk of elopement and his statements about leaving the facility. Resident #106, a 77-year-old male with a history of hypertension, arthritis, homelessness, and a previous myocardial infarction, was found to have traveled a significant distance from the facility in his wheelchair before being lost from video surveillance. The facility's failure to provide adequate supervision and a safe environment resulted in Immediate Jeopardy, as Resident #106 was exposed to significant risks, including heavy traffic and cold weather conditions. The facility did not conduct a root cause analysis or implement new interventions following the incidents, leading to a citation for Immediate Jeopardy at F-689 with a scope and severity of J.
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Surveyors found that staff did not follow the facility’s infection prevention policies, including Enhanced Barrier Precautions (EBP), hand hygiene, and urinary catheter management. A respiratory therapist performed trach care and suctioning for two residents with tracheostomies without donning required gowns or masks, placed supplies and an inner cannula on the resident’s abdomen and linens, and left a room wearing contaminated gloves. An RN administered meds via a feeding tube for a resident with a gastrostomy, then performed eyelid scrubs without changing gloves or performing hand hygiene between routes of care and without using a gown despite EBP signage. CNAs delivered and set up lunch trays for three residents who required at least some assistance with hygiene or meals but did not offer hand hygiene before eating, contrary to policy. In addition, a resident with a urinary catheter was observed in bed with the drainage bag lying on the floor, rather than suspended from the bed as confirmed by nursing staff and the IP.
Administration allowed an unqualified individual to be hired and work as an LPN by failing to verify licensure and reconcile name discrepancies across hiring documents. The individual’s I-9, birth certificate, and out-of-state driver’s license reflected one last name, while the TN LPN license verification on file belonged to a different nurse with the same first name but a different last name. Abuse registry checks were completed under both names, but no national background check or documentation explaining the differing names was present. The person was offered a temporary/contract LPN position, worked multiple shifts, and had conflicting separation notices, with no documentation of a formal rehire. The HR Director confirmed there was no hiring policy and that the individual worked onsite as an LPN before being terminated for failure to attend or complete training.
Administration failed to ensure nursing services were provided by qualified personnel when an unlicensed individual was hired and allowed to work as an RN and Unit Manager using another nurse’s license. Pre-employment documents for this staff member contained inconsistent SSNs and birth dates across the application, background check, W-4, and I-9, and the background report noted the SSN could not be validated. No abuse registry check or RN license verification was completed before hire, and a later license verification showed the last name on the RN license did not match the individual’s last name. The imposter, a walk-in applicant without a resume, worked multiple shifts providing nursing services before being separated as a voluntary termination, and facility staff did not question the documented discrepancies.
Administration allowed an unlicensed individual to be hired twice and function as an LPN using another LPN’s Tennessee license. During the first hire, conflicting SSNs appeared on the application and tax forms, the I‑9 identified the imposter by her own name and out‑of‑state driver’s license, and the license verification was for a different nurse with only the same first name; no Tennessee Abuse Registry check was documented, and the imposter worked multiple shifts before resigning. During the second hire, a different SSN was used, no I‑9 or supporting identity documents were on file, and the same other nurse’s license was again used for verification; the imposter worked several days before resigning. The Administrator reported that the same resume was used for both hires and that the facility had no formal hiring policy, only a checklist.
Administration failed to ensure nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s license. The facility’s own employment policy requiring HR completion of I-9 Section 2, consistent SSN use, and verification of license and abuse registry status was not followed. The imposter’s application and background check contained conflicting SSNs, names, and birthdates, and the I-9 was not signed by HR. An abuse registry check was run only on one SSN, and discrepancies were not investigated. Time records showed the imposter worked several shifts and had patient access, while leadership later confirmed she remained on the books until being treated as a voluntary termination for not picking up shifts.
Administration failed to ensure nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN under another nurse’s license. Facility records showed multiple unexplained discrepancies in the individual’s name, SSN, and birthdate across the background check, I-9, W-4, Consumer Information Sheet, and separation notice, and the I-9 was never completed or signed by facility staff. Time records confirmed the imposter worked several shifts as an RN before being terminated for no call/no show, and an abuse registry check was not completed until long after termination. The facility did not produce hiring policies or documentation that anyone questioned the conflicting identification information before or during this person’s employment.
Staff failed to honor a resident’s right to refuse care when CNAs proceeded with a scheduled shower despite the resident verbally declining. The resident, who had severe dementia with agitation and was dependent on staff for bathing, had a care plan directing staff to discuss objections, inform of risks, offer choices, and accept refusals. Instead, after the resident said they did not want a shower, one CNA pulled off the covers, and the CNAs placed the resident in a shower chair and continued with the shower because it was the resident’s assigned shower day, contrary to facility policy and the care plan.
A resident with severe cognitive impairment and multiple comorbidities was admitted for rehab and had clearly documented full code status in the face sheet, care plan, and physician orders. During the night, the resident was last observed awake and later found unresponsive with no heart sounds, pulse, or respirations. Staff initiated CPR and continued until the resident was pronounced deceased, but the record contained no evidence that EMS/911 was contacted or that an AED was obtained or used, despite facility policy and leadership expectations that full code residents receive CPR with 911 activation and AED use, and despite the presence of two AEDs in the facility.
A resident with severe cognitive impairment, type 2 DM, CKD, and a history of falls had physician orders for blood glucose checks before meals and at bedtime and for sliding scale insulin aspart four times daily. Facility policy required verification of insulin orders, blood glucose monitoring per orders, and documentation of results and doses. However, after an NP attempted to edit the sliding scale order in the EHR, the order remained unsigned and inactive in the queue, preventing it from appearing on the MAR. Nursing staff did not identify that the insulin order was missing, resulting in multiple missed blood glucose checks and insulin doses over several days, despite the resident’s care plan directing staff to follow physician orders for diabetes management.
The facility failed to maintain a clean and sanitary environment in multiple resident rooms and bathrooms, despite policies requiring routine cleaning and disinfection. Observations over several days found a motorized wheelchair and another wheelchair with attached cushion soiled with dried, multi-colored debris. Several resident bathrooms had unclean conditions, including a trash can without a liner and with dried brown residue, toilets with dried yellow residue on the seats, and yellow/orange or brown substances around the bases of multiple toilets. During an on-site check, the Administrator confirmed that the residue around one toilet could be wiped away and that the area was not clean.
Failure to Follow EBP, Hand Hygiene, and Catheter Practices During Respiratory, Enteral, and Daily Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies, including Enhanced Barrier Precautions (EBP), hand hygiene, and urinary catheter management. The facility’s EBP policy required staff to perform hand hygiene, review EBP signage, and don gown and gloves prior to high-contact resident care activities such as tracheostomy care, suctioning, and device care, then remove PPE and perform hand hygiene before leaving the resident’s room. For Resident #1, who had epilepsy, acute on chronic respiratory failure, a tracheostomy, and ventilator dependence, a respiratory therapist entered the room where EBP signage was posted, used pocket hand sanitizer, and donned gloves but did not don a gown or mask. The therapist placed clean gauze and used split gauze directly on the resident’s abdomen, allowed the tracheostomy inner cannula to roll from the abdomen onto the linens, and then left the room carrying a box while still wearing the same contaminated gloves, only discarding them later at the respiratory therapy cart. The therapist acknowledged not setting up supplies appropriately, not discarding gloves and performing hand hygiene before leaving the room, and not following EBP, stating she believed EBP was only required for residents with an active infection. For Resident #8, who had traumatic brain injury, quadriplegia, acute respiratory failure, and a tracheostomy, the same respiratory therapist again entered a room with EBP signage and donned gloves but no gown or mask before performing tracheal suctioning using an in-line suction catheter. The resident had reflex coughing during suctioning. After completing suctioning, the therapist discarded gloves and used pocket hand sanitizer but again did not follow the full EBP requirements. The infection preventionist later confirmed that EBP was required for high-contact care such as tracheal care and suctioning, and that gloves should be discarded before leaving the room with hand hygiene performed each time gloves are removed. The facility also failed to follow EBP and hand hygiene practices during medication administration for Resident #22, who had chronic respiratory failure, quadriplegia, tracheostomy status, and gastrostomy status, and who had long- and short-term memory deficits with severely impaired decision-making. A registered nurse entered the resident’s room, where EBP signage was posted, donned gloves but not a gown, and administered medications via the gastrostomy tube using a piston syringe, flushing with water as ordered. With the same used gloves still on, the nurse rinsed the piston syringe in the room sink, set it on paper towels to dry, and then performed OcuSoft eyelid scrubs to both eyes without changing gloves or performing hand hygiene between the different routes of care. The nurse confirmed she did not don a gown and did not perform hand hygiene or change gloves between the feeding tube medication administration and the eye care, and the infection preventionist confirmed that EBP and hand hygiene with glove changes were expected between administering medications by different routes. Additional deficiencies were identified in hand hygiene assistance before meals and urinary catheter management. The facility’s resident handwashing policy required staff to offer hand hygiene before meals. Resident #47, who had acute and chronic respiratory failure, epilepsy, atrial fibrillation, and chronic pulmonary edema and was dependent for hygiene and feeding assistance, received a lunch tray from a CNA who set up the tray and left without offering hand hygiene assistance. Resident #31, with COPD, acute and chronic respiratory failure, morbid obesity, and a care plan indicating partial to moderate assistance with hygiene, also had a lunch tray delivered and set up by a CNA who exited without offering hand hygiene. Resident #66, with COPD, chronic respiratory failure, generalized muscle weakness, and substantial to maximal ADL needs including meal assistance, likewise had a lunch tray delivered and set up without being offered hand hygiene. One CNA acknowledged residents were to be offered hand hygiene before meals, and another stated she had not offered hand hygiene unless residents mentioned it. The infection preventionist confirmed staff were expected to offer hand hygiene assistance to all residents prior to meals. The facility further failed to maintain proper urinary catheter bag positioning for Resident #15, who had chronic osteomyelitis, depression, anxiety, paraplegia, and required assistance with ADLs, including urinary catheter care per orders and protocol. During observation, the resident was in bed with the urinary catheter drainage bag lying on the floor beside the bed. A licensed practical nurse confirmed the catheter bag should be hung from the bed, and the infection preventionist confirmed catheter bags were to be suspended off the ground to prevent infection. These observations demonstrated non-adherence to the facility’s infection prevention and control practices related to EBP, hand hygiene, and catheter management across multiple residents and care situations.
Imposter Hired and Employed as LPN Without Proper License Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an LPN using another nurse’s Tennessee license. Personnel file review showed that the individual, referred to as Imposter Nurse A, had an I-9 form completed with her legal first and last name, supported by a birth certificate and an out-of-state driver’s license, and a Tennessee Criminal History Record Request indicating no Tennessee criminal history under that name. However, the nursing license verification in the file was for a different person, an LPN with the same first name but a different last name (LPN C). Two Tennessee Abuse Registry checks were present, one under LPN C’s name and one under Imposter Nurse A’s name, but there was no documentation explaining or reconciling the name discrepancies between the I-9, the license verification, and other employment documents. There was also no national background check in the personnel file. The facility issued an offer letter to Imposter Nurse A for a temporary/contract LPN position, and time sheets showed she worked multiple shifts on several dates. Two separation notices documented voluntary separation without notice, with differing last days worked, and there was no paperwork provided to explain her apparent rehire after the first termination. During interview, the Human Resource Director acknowledged there was no hiring policy, confirmed that Imposter Nurse A worked onsite as an LPN, and stated she was terminated for failure to attend or complete training and for failure to come in as needed. No information was provided to surveyors showing any cross-check or investigation of the inconsistent names across the employment application, I-9 form, and nursing license verification, resulting in the facility employing an unqualified person in an LPN role.
Imposter RN Hired and Allowed to Function Without Proper Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s Tennessee license. Facility policy titled “Abuse Program Policy” required pre-employment screening, including obtaining a copy of the state license for licensed positions and completing a criminal background check per state statute. The application for employment for the imposter nurse contained a scratched-out Social Security Number (SSN) with a different SSN written above that did not match the SSN on the I-9 form, and the birth date on the application also did not match the I-9. The background screening report showed an SSN and birth date that did not match the I-9 and included a note stating “UNABLE TO VALIDATE SSN.” A W-4 form contained an SSN that did not match the background check. The I-9 form listed the imposter’s legal first and last name, with a Social Security card and valid Tennessee driver’s license, but the birth date on the I-9 differed from the birth date on the background check. Review of the personnel file revealed no evidence that an abuse registry check was completed prior to hire, and there was no evidence that a license verification was done before the imposter nurse’s start date. Time cards showed the imposter worked multiple days in February and March as a Unit Manager. A later QuickConfirm license verification showed that the last name on the validated RN license did not match the imposter’s last name. Interviews with the DON, HR representative, and Administrator confirmed that the imposter was a walk-in applicant who did not provide a resume, that in-house HR was responsible for ordering background checks with corporate as backup, and that the imposter worked in the facility as a Unit Manager and was only separated as a voluntary termination for inability to uphold weekend schedule obligations. There was no evidence that the facility questioned the discrepancies in names, birth dates, or SSNs on the pre-employment documents, resulting in the employment of an unqualified person to render nursing services as an RN.
Imposter Nurse Hired Twice and Allowed to Function as LPN Without Proper Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and allowed to function as an LPN on two separate occasions using another nurse’s Tennessee license. For the first hire, the personnel file showed an employment application dated 02/08/2023 with a Social Security Number (SSN) that did not match the SSN on the W‑4 form dated 02/13/2023. The I‑9 form dated 02/13/2023 listed the imposter’s legal first and last name, supported by a birth certificate and an out‑of‑state driver’s license, and the last name on the I‑9 matched the driver’s license. However, the license verification form in the file was for a different individual, an LPN with the same first name but a different last name, and there was no evidence that a Tennessee Abuse Registry check was completed prior to the 02/13/2023 hire date. Time punch records showed the imposter worked multiple shifts in February, March, April, and May 2023 before being terminated on 06/06/2023, with the termination form citing voluntary resignation due to chronic absenteeism and tardiness. For the second hire, the imposter was rehired with a personnel file showing that the SSN on the employment application, W‑4, and background check matched each other but differed from the two SSNs used during the first hire, meaning three different SSNs were used across the two employment periods. There was no I‑9 form or supporting identity documents in the file for the rehire. A license verification form again showed a nursing license in the name of the same LPN whose license had been used previously, with the same first name as the imposter but a different last name and a later expiration date. The background screening report dated 02/13/2024 used the SSN from the employee application, which did not match the SSN previously submitted on the I‑9 form from the first hire. Time punch data showed the imposter worked several days in May 2024 before a termination dated 06/24/2024, which documented voluntary resignation after failing to provide a schedule and not returning after orientation. In an interview, the Administrator stated the facility used the same resume for both hires and that the facility did not have a hiring policy, only a checklist.
Imposter RN Hired and Allowed to Work Without Proper License Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s Tennessee RN license. The facility’s Employment policy required the HR Director to complete Section 2 of the I-9, conduct background investigations, and verify licenses and abuse registry status using the applicant’s registration or Social Security number. Review of the imposter’s employment application showed a Social Security number scratched out and replaced with another number that did not match the SSN used on the background check. The background check listed both the imposter’s name and the legitimate RN’s name, and it showed the legitimate RN’s license number. The birthdate on the I-9 did not match the birthdate on the background check, and Section 2 of the I-9 was not signed by the HR Director as required by policy. Further review showed that an abuse registry search was completed using the SSN from the Social Security card submitted with the I-9, but no search was conducted using the SSN listed on the background check. The separation notice for the imposter listed her real first and last name with an SSN that again did not match the SSN on the background check, and documented employment from mid-June to late November with the reason for termination as voluntary due to not picking up shifts for over three months. Employee time entries showed the imposter worked multiple days in June and one day in July. The DON confirmed that the imposter used an online artificial intelligence website for charting and stated the imposter had access to patients for one day in July. The Administrator confirmed the imposter was considered employed during the stated period and was not formally fired or documented as having quit. There was no evidence that the facility questioned the discrepancies in names, birthdates, or Social Security numbers on the pre-employment documents, resulting in the employment of an unqualified person as an RN.
Imposter RN Hired and Allowed to Work Despite Multiple Identification Discrepancies
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s Tennessee license. Personnel file and document review showed multiple inconsistencies in the imposter nurse’s identifying information that were not questioned by the facility. The background check dated 06/14/2024 used a Social Security Number (SSN) that did not match the SSN on the Social Security card submitted. The I-9 form dated 06/15/2024 listed the imposter’s legal first and last name, with a copy of her Social Security card and a valid Tennessee driver’s license, but the SSN on the I-9 did not match the SSN on the Social Security card. The I-9 form was not completed, signed, or dated by any facility representative. Time punch data showed the imposter nurse worked multiple days in June and July 2024. A separation notice dated 07/31/2024 listed the imposter’s real first and last name with an SSN that did not match the SSN on the I-9 form, and documented employment dates from 06/12/2024 to 07/31/2024 with termination for no call/no show. An undated Consumer Information Sheet listed the imposter’s first and last name with the legitimate RN’s last name as her middle name, a birth year that did not match the I-9, and an SSN that did not match the SSN on the W-4 form or the separation notice. The abuse registry check for the imposter was not completed until 08/04/2025, after termination. The facility did not provide any hiring policies and there was no evidence that staff questioned the discrepancies in names, birth dates, or SSNs on the pre-employment forms, resulting in the employment of an unqualified person as an RN.
Failure to Honor Resident’s Refusal of Shower and Right to Self-Determination
Penalty
Summary
The deficiency involves staff failure to honor a resident’s right to self-determination and refusal of treatment, specifically related to bathing. Facility policy on Resident Rights and Responsibilities states that residents have the right to refuse treatment and to be informed of the medical consequences of such refusal, and to exercise their rights without discrimination or reprisal. Resident #31, admitted in late 2023, had severe dementia with agitation, a BIMS score of 3 indicating severe cognitive impairment, and was dependent on staff for showering and personal hygiene. The resident’s care plan identified behavior problems and resistance to care related to dementia, knowledge deficit, denial of illness and risk factors, and mental/emotional illness, with interventions directing staff to discuss objections and fears, inform the resident of risks of non-compliance, offer choices, and accept and respect the resident’s right to refuse care. Despite these policies and care plan interventions, staff proceeded with a shower after the resident refused. A CNA assigned to the resident reported that the resident had refused a shower, and another CNA responded that it was the resident’s shower day and that the shower should be provided. According to written statements, when the CNAs entered the room and informed the resident it was shower day, the resident stated, “No I don’t want a shower.” One CNA then told the resident they were getting a shower and pulled the covers off the resident. The CNAs placed the resident in a shower chair and continued with the shower despite the expressed refusal. During a later interview, the CNA confirmed instructing the other staff member to go ahead and provide the shower because it was the resident’s scheduled shower day, demonstrating that the resident’s right to refuse care and the care plan interventions to respect refusals were not followed.
Failure to Contact EMS and Use AED During CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its CPR and emergency response policy for a resident who was a documented full code. Facility policy required staff to call 911 for resident emergencies, obtain and use an AED, and initiate CPR for full code residents unless there was a POST form or other physician order to withhold CPR, or the resident showed American Heart Association (AHA) signs of clinical death. The 2020 AHA Adult Basic Life Support Algorithm directs healthcare providers to activate the emergency response system, obtain an AED, and use it as soon as available when a person has no breathing or only gasping and no pulse. The facility had two AEDs and staff were educated on AED use as part of CPR training. Resident #78 was admitted for rehabilitation and 24-hour skilled nursing care following a hospitalization due to a fall at home and had a medical history including atrial fibrillation with multiple cardioversions, dysphagia, chronic kidney disease, mild cognitive impairment with memory loss, hypertension, UTI, influenza, and type 2 diabetes mellitus. The resident’s profile, care plan, and physician’s orders all documented full code status. A 5-day MDS showed a BIMS score of 4, indicating severe cognitive impairment. On the evening prior to the event, an RN documented that the resident was sitting in a wheelchair watching television at 8:20 PM, was assisted to the bathroom at 10:00 PM, and was checked again at 12:00 AM. At approximately 2:00 AM, a CNA found the resident unresponsive and notified the RN, who assessed the resident and documented no heart sounds, pulse, or respirations. Staff initiated CPR and continued efforts until the RN pronounced the resident deceased at 2:45 AM. There was no documentation in the medical record that EMS/911 was contacted or that an AED was used during the resuscitation attempt, despite facility policy and the expectations stated by the DON, LPN, NP, and Medical Director that staff should call 911, obtain and use an AED, and continue CPR until EMS arrival for a full code resident. An email from the local fire department indicated there were no EMS reports for the resident on the date in question, and the DON stated she had no evidence to verify that EMS was contacted and no AED log to show whether an AED was used. The Administrator stated she expected staff to follow the CPR policy and properly document all care and services provided, but the record lacked evidence of EMS notification or AED utilization for this full code resident.
Failure to Activate and Follow Sliding Scale Insulin and Blood Glucose Orders
Penalty
Summary
The deficiency involves the facility’s failure to activate and carry out physician orders for blood glucose monitoring and sliding scale insulin for a resident with type 2 diabetes. Facility policy on insulin administration required verification that insulin type, dosage, strength, and method of administration corresponded with the physician’s order, checking blood glucose per physician order or facility protocol, and documenting blood glucose results and insulin doses. The resident’s care plan for diabetes directed staff to check blood sugar levels via fingerstick per physician orders and to administer medications per physician orders. The resident was admitted for rehabilitation and 24-hour skilled nursing care following a hospitalization due to a fall at home and had a medical history that included chronic kidney disease and type 2 diabetes mellitus. A 5-day MDS showed severe cognitive impairment with a BIMS score of 4 and an active diagnosis of type 2 diabetes, with insulin injections received. Physician orders directed staff to check the resident’s blood sugar before meals and at bedtime, four times a day, and to administer insulin aspart via a sliding scale four times a day. These orders were in place with a specified stop date and then renewed. Despite these orders, the medication record for the resident showed no documentation of blood sugar levels or administration of insulin aspart at multiple ordered times over several days. A family member reported concern that the resident’s blood sugar levels had not been checked for the past couple of days and that the resident was not on a short-acting insulin. A medication error report later identified that the NP had updated the sliding scale insulin order, but the update was not signed and remained in the unsigned order queue, leaving the insulin aspart order inactive on the MAR. As a result, nursing staff could not see the updated order and missed multiple doses of insulin aspart. The NP stated that she had intended to edit, not discontinue, the sliding scale order, but the electronic medical record required her to unsign the order to edit it, and she failed to reactivate it. The DON stated that nursing staff failed to identify that the insulin aspart order was missing and remained in the queue awaiting reactivation, and the Administrator stated that her expectation was for staff to follow company policy and for the DON or designee to verify that all active orders were visible for nurses when a plan of correction for missing insulin doses had been implemented. A physician statement documented that the resident had uncontrolled type 2 diabetes mellitus, CKD stage III, and hyperlipidemia, and that the resident received sliding scale insulin on one day but did not receive any sliding scale insulin on the following two days. The physician noted that the resident’s blood glucose reached a maximum level of 343 mg/dL during this period and that the sliding scale insulin order was later replaced and resumed. These findings collectively show that the facility did not provide treatment and care according to physician orders and the resident’s care plan for diabetes management, due to the failure to activate and monitor the sliding scale insulin and blood glucose orders in the electronic system and to recognize and correct the missing active order on the MAR.
Failure to Maintain Clean and Sanitary Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean and sanitary environment in multiple resident rooms and bathrooms, contrary to its own policies on routine bathroom cleaning and routine cleaning and disinfection. The facility’s policies, dated 6/2025, required providing a clean and sanitary environment, cleaning the entire toilet including the handle and underside of the flush rim with disinfectant and appropriate contact time, and reporting damaged items in need of repair. Observations conducted on several days showed that in one room, a motorized wheelchair had dried debris on the cushion, arms, and a large amount of multi-colored debris on the undercarriage. In another room, a wheelchair with a fabric heel protector cushion used as an armrest was spattered with small to pea-sized unknown multi-colored particles. Additional observations revealed that several resident bathrooms were not maintained in a sanitary condition. One bathroom had a trash can without a bag and with a dried brown substance on the outside, rim, and inside of the can, as well as a toilet seat with two areas of dried yellow residue and a yellow/orange substance around the base of the toilet. Other bathrooms in different rooms had yellow/orange or brown residue around or at the front base of the toilets. During an observation and interview in one of the bathrooms, the Administrator initially suggested the substance around the toilets might be related to the wax ring, but after wiping a small area with a wet wipe, the yellow/orange substance was easily removed, and the Administrator confirmed the area around the toilet was not clean.
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