Greystone Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Blountville, Tennessee.
- Location
- 181 Dunlap Road, Blountville, Tennessee 37617
- CMS Provider Number
- 445242
- Inspections on file
- 23
- Latest survey
- May 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Greystone Health Care Center during CMS and state inspections, most recent first.
A resident who was hospitalized for an extended period returned to find personal belongings, including a statue and a decorated tree, missing from their room. Facility staff reported that items left behind were boxed, labeled, and stored, but those unclaimed after 30 days were discarded per previous administrative instruction. The resident's family was not notified prior to the disposal, and the facility lacked a policy on handling personal items after a resident's absence.
The facility failed to follow the manufacturer's instructions for using Virasept disinfectant, as observed when a housekeeper did not maintain the required four-minute wet time on a doorknob. Interviews confirmed the deficiency, highlighting a lapse in the infection prevention and control program.
The facility did not include the resident census, facility name, or actual hours worked by RNs, LPNs, and CNAs on the Daily Staffing Sheets for three consecutive days. This was confirmed by the Staffing/Central Supply Coordinator and the DON during interviews.
The facility failed to maintain kitchen equipment in a sanitary condition, ensure spices were properly sealed, and discard expired food, potentially affecting 92 of 95 residents. Observations revealed unsealed seasoning salt, expired wing sauce, a greasy film with food particles behind the deep fryer, and a leaking pipe under the dirty sink area. The Certified Dietary Manager confirmed these deficiencies, acknowledging that the kitchen areas were not maintained in a clean sanitary manner.
The facility failed to document Durable Power of Attorney (POA) for two residents and did not provide education on Advance Directives to six residents upon admission. Residents had varying cognitive impairments, and interviews confirmed the absence of necessary documentation and education.
The facility failed to properly contain garbage and refuse in all three dumpsters, as observed during an inspection. The facility's policy requires trash to be disposed of in external receptacles with the surrounding area free of debris. However, the dumpster area was found with scattered refuse, including used gloves, plastic cups, wipes, straws, spoons, and a trash-filled plastic bag, confirming it was not maintained in a clean and sanitary condition.
The facility failed to provide hand hygiene assistance to eight residents before meals, as observed on two hallways. CNAs and an LPN delivered meal trays without offering hand hygiene, contrary to the facility's infection control protocols. Staff interviews confirmed this oversight, and the DON acknowledged the expectation for hand hygiene assistance prior to meals.
The facility did not adequately address grievances from residents regarding staff behavior and meal options. Residents complained about staff yelling and cursing in hallways and requested more fresh fruits in meals. The Dietary Manager only added a fresh fruit bar once, and the DON did not address the staff behavior issue, as no staff admitted to it. These grievances were not promptly acted upon, affecting 12 residents.
The facility failed to provide ABNs to three residents after discontinuing their therapy services, contrary to its policy. This omission left residents uninformed about potential costs for continued therapy, preventing informed decision-making. The residents had various medical conditions and were discharged from skilled Medicare services without receiving the required notices.
A facility failed to maintain a safe and sanitary environment for a resident, with issues including a strong urine odor, stained curtains, and unclean personal refrigerators. Observations revealed undated food items and expired milk in the refrigerator. Interviews highlighted confusion among staff regarding responsibilities for cleaning and temperature checks.
The facility failed to submit updated Level 2 PASARRs for two residents after new psychiatric diagnoses were identified. One resident was diagnosed with PTSD and another with an Unspecified Mood Disorder, but neither had a new PASARR submitted following these changes. The PASARR Coordinator confirmed the expectation for referrals after new diagnoses.
The facility failed to maintain clean oxygen equipment for two residents, both of whom had soiled oxygen concentrators beside their beds. Interviews revealed confusion among staff regarding responsibility for cleaning the equipment, with the DON confirming that nursing staff were responsible but had not maintained the equipment in a sanitary condition.
A resident with COPD and other conditions did not receive proper instructions or follow-up care during the administration of an oral inhaler by an LPN. The facility's policy, which includes steps for safe inhaler use and mouth rinsing, was not followed, as confirmed by the LPN and DON.
The facility failed to securely store Schedule II pain medication in one of its medication rooms. During an observation, 27 tablets were found in an unlocked refrigerator, contrary to the facility's policy requiring double-lock storage. This was confirmed by an RN and the DON.
A facility failed to secure a laptop containing electronic health records on a medication cart, resulting in resident information being visible to unauthorized persons. The incident occurred when a laptop screen was left unattended and unlocked in the 100 Hallway, as confirmed by an RN and the DON, who acknowledged the breach of facility policy.
A resident with moderate cognitive impairment and multiple health conditions was found without access to her call light, which was placed in a bedside drawer instead of within her reach. This oversight was confirmed by both a CNA and an LPN, highlighting a failure to adhere to the facility's policy on call light accessibility.
The facility failed to protect residents from abuse, resulting in incidents of inappropriate behavior and physical altercations. A cognitively impaired resident was inappropriately touched by another resident, leading to one-on-one supervision. Another incident involved a physical altercation between two residents, resulting in a skin tear and a facial scratch. Additionally, a resident was hit with a soda can by another resident, though no injuries were reported. These incidents indicate a failure to ensure resident safety.
A resident with multiple diagnoses, including COPD and Major Depressive Disorder, was administered Lorazepam without a valid physician's order. The medication was given after the order had been discontinued, as confirmed by interviews with an RN and an LPN.
Failure to Safeguard Resident's Personal Belongings After Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's right to retain personal possessions following a hospitalization. The resident, who was cognitively intact and dependent on ventilator and personal care, was hospitalized for approximately one month. Upon return, the resident and their family discovered that personal belongings, including a statue and a small decorated tree, were missing from the resident's room. The family reported the missing items to facility staff, but the items could not be located. The Housekeeping Manager confirmed that some items, such as a journal and devotional book, were found and returned, but the statue and tree were not recovered. Facility staff interviews revealed that housekeeping boxed and labeled resident belongings and stored them on the third floor when a resident left the facility. Items stored for 30 days or more were discarded, following instructions from a previous administrator, due to storage space limitations. The Social Services Director and Social Worker did not recall contacting the resident's family to notify them about the impending disposal of the belongings. The facility did not have a policy regarding the disposal of resident personal items, and the Regional Clinical Director was unaware of the 30-day discard practice.
Failure to Follow Disinfectant Instructions
Penalty
Summary
The facility failed to adhere to the manufacturer's instructions for using a disinfectant, Virasept, on one of the hallways observed. The facility's documentation outlined the importance of following the manufacturer's recommended dwell time for disinfectants to effectively sanitize surfaces. According to the manufacturer's instructions, Virasept requires a surface to remain wet for at least four minutes to be effective. However, during an observation, a housekeeper was seen disinfecting a doorknob with Virasept, but the surface dried within three minutes, and the housekeeper did not reapply the solution to maintain the required wet time. Interviews with the housekeeping manager and the housekeeper confirmed the deficiency. The housekeeping manager stated that the surface must remain wet for four minutes, as per the instructions, and the housekeeper acknowledged that the doorknob was not wet for the required duration. This failure to comply with the manufacturer's instructions for disinfectant use could potentially compromise the facility's infection prevention and control program, particularly in preventing the spread of infectious organisms like Candida auris.
Incomplete Daily Staff Posting Information
Penalty
Summary
The facility failed to ensure that daily staff posting information was complete and accurate for three consecutive days. Specifically, the Daily Staffing Sheets from October 28, 2024, to October 30, 2024, did not include the resident census, the facility name, or the actual number of hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs). This deficiency was confirmed through a review of the facility's policy on required postings, observations, and interviews with the Staffing/Central Supply Coordinator and the Director of Nursing (DON). Both the Staffing/Central Supply Coordinator and the DON acknowledged the omissions in the staffing sheets during interviews conducted on October 30, 2024.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain kitchen equipment in a sanitary condition, ensure spices were properly sealed, and discard expired food, potentially affecting 92 of 95 residents. During an observation of the food preparation area, a 12-ounce bottle of salt and pepper seasoning salt was found unsealed and available for use. Additionally, an unopened container of mild wing sauce with an expired date was available for use. The area behind the deep fryer was observed to have a greasy film with food particles, indicating a lack of cleanliness. Further observations revealed a pipe under the dirty sink area actively dripping significant amounts of water into a full bucket of cloudy water, with moist food particles on the wall. The Certified Dietary Manager (CDM) confirmed that the equipment and floors were cleaned daily but acknowledged the presence of the greasy film and food particles behind the deep fryer. The CDM also confirmed the leaking pipe and the presence of the bucket of cloudy water and food particles on the wall. The CDM admitted that the kitchen areas had not been maintained in a clean sanitary manner, and the expired wing sauce and unsealed seasoning salt were confirmed to be available for use.
Failure to Document POA and Provide Advance Directive Education
Penalty
Summary
The facility failed to ensure that Durable Power of Attorney (POA) documents were entered into the medical records for two residents and did not provide education regarding Advance Directives upon admission for six residents. Resident #23, who was admitted with severe cognitive impairment, had a previously formulated POA, but the document was not included in the medical record. Similarly, Resident #86, with moderate cognitive impairment, had family members who chose to execute advance directives, but these documents were also missing from the medical record. Additionally, the facility did not provide education on advance directives to six residents or their representatives upon admission. These residents had varying levels of cognitive impairment, as indicated by their Brief Interview for Mental Status (BIMS) scores, ranging from severe to cognitively intact. Despite this, there was no documentation of education provided to them or their representatives about their rights to formulate an advance directive. Interviews with the Social Services Director and the Admissions Director confirmed these deficiencies. The Social Services Director acknowledged the absence of the POA document for Resident #23 and the lack of execution of advance directives for Resident #86. The Admissions Director confirmed that education on advance directives was not provided to the six residents or their representatives at the time of admission.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that garbage and refuse were properly contained in all three of its dumpsters. According to the facility's policy titled 'Environment,' revised in September 2017, trash should be properly disposed of in external receptacles, and the surrounding area should be free of debris. However, during an observation and interview conducted on October 28, 2024, at 12:00 PM, the Certified Dietary Manager (CDM) confirmed that the outside dumpster area contained scattered refuse. This included used gloves, plastic medicine cups, plastic drinking cups, used wipes, drinking straws, plastic spoons, and a clear plastic bag filled with trash, indicating that the area was not maintained in a clean and sanitary condition.
Failure to Provide Hand Hygiene Assistance Before Meals
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not offering hand hygiene assistance to eight residents before meals. This deficiency was observed during meal service on two of the three hallways. The facility's document titled 'Validation Checklist Hand Hygiene' indicated that residents should be offered hand hygiene prior to meals, but this protocol was not followed. Observations on the 300 and 200 Hallways revealed that CNAs and an LPN delivered meal trays to residents without offering hand hygiene assistance. Interviews with the staff confirmed the lack of hand hygiene assistance. CNA F, CNA G, CNA H, and LPN D all acknowledged that they did not offer hand hygiene assistance to the residents before setting up their meal trays. The Director of Nursing confirmed that it was the facility's expectation for residents to be offered hand hygiene assistance prior to meals, indicating a failure to meet the facility's own standards for infection control.
Facility Fails to Address Resident Grievances
Penalty
Summary
The facility failed to address grievances raised by residents during a resident council meeting. The grievances included complaints about staff yelling and cursing in the hallways and a request for more fresh fruits in meals. Despite these concerns being documented in the Resident Council Minutes from August 16, 2024, the facility did not take adequate action. The Dietary Manager acknowledged the request for more fresh fruits but only added a fresh fruit bar once in September, with no further action. The Director of Nursing was aware of the complaints about staff behavior but did not take steps to address the issue, as no staff admitted to the behavior, and she was unaware of ongoing concerns. As a result, the facility did not act promptly on the residents' grievances, affecting 12 residents who attended the October 29, 2024, meeting.
Failure to Provide Advanced Beneficiary Notices
Penalty
Summary
The facility failed to provide Advanced Beneficiary Notices (ABNs) to three residents after their therapy services were discontinued. This failure occurred despite the facility's policy, which mandates timely notices regarding Medicare eligibility and coverage when Medicare-covered services are ending. The absence of these notices meant that the residents were not informed of the potential costs of continuing therapy services, thereby not allowing them to make an informed choice. The residents involved included individuals with various medical conditions such as Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Chronic Diastolic Congestive Heart Failure, and a history of Transient Ischemic Attack. Each resident was discharged from skilled Medicare services on different dates, yet none received the required ABN. The facility's administrator confirmed during an interview that the notices were not provided to the residents prior to their discharge from skilled Medicare services.
Deficiency in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide effective housekeeping and maintenance services to ensure a safe, sanitary, and homelike environment for a resident. Observations revealed a strong urine odor in the resident's room, dark brown substances on the walls, and rust-colored substances around the air conditioning unit. Dried food was found inside the vent area of the air conditioning unit, and stains were observed on the window curtains. The Housekeeping Director confirmed these findings and acknowledged that the room was not in a sanitary condition. Additionally, the facility did not maintain the resident's personal refrigerator in a sanitary condition. Observations showed a dark brown dried liquid substance inside the refrigerator, along with undated food items and expired milk. Interviews with the 2nd Floor Unit Manager and the Housekeeping Director revealed confusion regarding the responsibility for cleaning the personal refrigerators and performing temperature checks. The Administrator admitted to not knowing who was responsible for these tasks, indicating a lack of clarity in the facility's procedures.
Failure to Update PASARR for New Psychiatric Diagnoses
Penalty
Summary
The facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASARR) for two residents following new psychiatric diagnoses. Resident #7 was admitted with diagnoses including Dementia, Bipolar Disorder, and Psychosis. A review of the medical records revealed that Resident #7's PASARR, dated 9/29/2023, did not include a diagnosis of Post Traumatic Stress Disorder (PTSD). A psychiatric evaluation on 12/5/2023 identified PTSD as a new diagnosis, but a new PASARR was not submitted following this change. Similarly, Resident #37 was admitted with diagnoses including Dementia, Muscle Weakness, and Generalized Anxiety. The medical records showed that Resident #37's PASARR, dated 9/26/2023, did not include a diagnosis of Unspecified Mood Disorder. A psychiatric evaluation on 12/20/2023 revealed this new diagnosis, yet a new PASARR was not submitted. During an interview, the PASARR Coordinator confirmed that it was expected for both residents to have been referred for a Level 2 PASARR evaluation after their new diagnoses were identified.
Failure to Maintain Clean Oxygen Equipment
Penalty
Summary
The facility failed to maintain resident-care oxygen equipment in a clean and sanitary condition for two residents observed for oxygen use. Resident #23, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Stroke, Dementia, Weakness, and Obstructive Sleep Apnea, had a blue 5-liter oxygen concentrator beside their bed that was observed to be soiled with a tan brown-like substance on two separate occasions. Similarly, Resident #50, admitted with Alzheimer's Disease, Heart Failure, COPD, and Dementia, had a black 10-liter oxygen concentrator beside their bed that was also observed to be soiled with a tan brown-like substance on two separate occasions. Interviews with facility staff revealed a lack of clarity regarding responsibility for cleaning the oxygen concentrators. The Respiratory Therapist stated that nursing staff were responsible for cleaning the equipment, while a Registered Nurse on the 2nd floor believed it was the responsibility of the respiratory therapy staff. The Director of Nursing confirmed that nursing staff were responsible for cleaning the concentrators when visibly soiled and acknowledged that the equipment for both residents was not maintained in a clean and sanitary condition. The Respiratory Therapy Manager also stated that nursing staff were responsible for cleaning the oxygen concentrators on the 2nd floor.
Failure to Properly Administer Oral Inhaler
Penalty
Summary
The facility failed to ensure proper administration of an oral inhaler for a resident, identified as Resident #52, who was observed during medication administration. The facility's policy on medication administration for oral inhalations, dated January 2023, outlines specific steps for safe and effective use, including instructing the resident to breathe out before inhaling, pressing the inhaler as the resident breathes in, and having the resident rinse their mouth after using a steroid inhaler. However, during an observation on October 29, 2024, at 7:00 AM, an LPN administered the inhaler to Resident #52 without providing any instructions or ensuring the resident rinsed their mouth afterward. Resident #52, who was admitted with diagnoses including Hemiplegia, Hemiparesis, Morbid Obesity, and Chronic Obstructive Pulmonary Disease, was noted to be cognitively intact with a BIMS score of 15. Despite this, the LPN did not follow the facility's policy, as confirmed in an interview later that day. The Director of Nursing also confirmed on October 30, 2024, that the facility's policy for administering oral inhalations was not adhered to in this instance.
Improper Storage of Schedule II Medications
Penalty
Summary
The facility failed to ensure the proper and secure storage of medications in one of its medication storage rooms. During an observation of the 2nd floor medication room, it was found that 27 oral tablets of a Schedule II pain medication were stored in an unlocked refrigerator. This was confirmed by RN A, who acknowledged that the Schedule II pain medication was not stored under the required double-lock system, as the refrigerator was unlocked. The Director of Nursing also confirmed that the facility's policy for the storage of Schedule II medications was not followed.
Unsecured Electronic Health Records on Medication Cart
Penalty
Summary
The facility failed to secure a device containing electronic health records, leading to a breach of resident-identifiable information. During an observation, it was noted that a laptop screen attached to a medication cart in the 100 Hallway was left unattended and unlocked, displaying resident information visible to unauthorized persons. This incident was confirmed by RN E, who acknowledged that the resident information was accessible to unauthorized individuals. The Director of Nursing stated that the facility's policy required laptop screens on unattended medication carts to be locked, confirming that this expectation was not met when RN E left the laptop screen unlocked.
Resident's Call Light Inaccessible
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by their policy on call light accessibility and timely response. Resident #50, who was admitted with diagnoses including Malignant Neoplasm of the Lung, Psychosis, and Diabetes, and had a moderate cognitive impairment, was observed asking for her nurse while her call light was found in a bedside drawer, out of her reach. The resident was dependent on assistance for eating, toileting, and dressing. A CNA noted that the call light was placed on the resident's belly earlier in the day, but it was later found in the drawer, which was partially closed. An LPN confirmed the call light's location, indicating a failure to ensure the resident's access to the call system.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in incidents involving inappropriate behavior and physical altercations among residents. One incident involved a resident with severe cognitive impairment who was nonverbal and dependent on staff for all activities of daily living. This resident was inappropriately touched by another resident who was cognitively intact. Despite the resident's nonverbal cues indicating distress, the inappropriate behavior was observed by staff, and the resident was placed on one-on-one supervision following the incident. Another incident involved two residents, one of whom had severe cognitive impairment and the other who was cognitively intact. The cognitively impaired resident entered the room of the other resident, leading to a physical altercation where one resident sustained a skin tear and the other a facial scratch. The facility's documentation and interviews confirmed that both residents were harmed during this altercation. A third incident involved a cognitively intact resident who hit another resident with a soda can after the latter touched the former's drink. The resident who was hit did not sustain any injuries and reported feeling safe in the facility. These incidents highlight the facility's failure to protect residents from abuse and ensure their safety, as required by their policies.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident, identified as Resident #26, among 15 residents reviewed. Resident #26 was admitted with diagnoses including Acute Respiratory Failure, COPD, Major Depressive Disorder, and Dysphagia, and was cognitively intact as per the admission MDS assessment. A physician's order dated June 28, 2024, prescribed Lorazepam 0.5 mg by mouth every 4 hours as needed for anxiety/seizure precaution, with an end date of July 12, 2024. However, the Narcotic Log indicated that Lorazepam was removed from the medication cart and administered to the resident on July 23, 2024, after the order had been discontinued. Interviews with RN K and LPN L confirmed the administration of Lorazepam to Resident #26 without a valid physician's order.
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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