Heritage Center, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Morristown, Tennessee.
- Location
- 1026 Mcfarland Street, Morristown, Tennessee 37814
- CMS Provider Number
- 445215
- Inspections on file
- 20
- Latest survey
- June 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Heritage Center, The during CMS and state inspections, most recent first.
The facility did not fully complete required dialysis communication records for two residents with end-stage renal disease and other chronic conditions. Documentation lapses included missing pre- and post-dialysis weights, vital signs, and access site checks, despite facility policy and contract requirements. The DON confirmed the forms were not completed as required.
A resident with End Stage Renal Disease and other chronic conditions was ordered and received hemodialysis treatments as documented in the medical record and care plan. However, the admission MDS assessment did not accurately reflect the dialysis treatments received, as confirmed by the Clinical Reimbursement Specialist during record review.
A resident with multiple chronic conditions and a permacath for dialysis did not have a comprehensive care plan addressing the vascular access site or Enhanced Barrier Precautions, as required by facility policy. The omission was confirmed by the DON after review of the resident's records and observation.
Surveyors observed that expired Heparin lock flush syringes were present and accessible in a medication storage room. Both the SDC and DON confirmed that these expired IV medications should have been discarded according to facility policy, but were instead available for use.
A resident with cognitive impairment and swallowing difficulties, who had a physician order and care plan for a divided plate at meals, was observed being served food on a regular plate during multiple meals. Staff and leadership confirmed the need for the assistive device and acknowledged it was not provided as required.
A resident with multiple chronic conditions and moderate cognitive impairment was found to have three expired, unopened nutritional shakes in their personal refrigerator. Facility policy required weekly checks and removal of expired food items, but staff interviews revealed confusion about responsibility for this task, and the DON confirmed the expired items should have been discarded.
A resident with end stage renal disease and a permacath for dialysis had their access site assessments inaccurately documented by LPNs, who recorded assessments for a shunt site instead of the actual permacath. Although staff assessed the correct site, the MAR did not accurately reflect the care provided, as confirmed by the DON.
Staff failed to provide hand hygiene assistance before meals to three residents who required help, did not use required PPE (gown and gloves) during feeding tube care for a resident on Enhanced Barrier Precautions, and improperly stored an ice scoop during meal service, leaving ice exposed to potential contamination.
The facility failed to maintain sanitary kitchen equipment, affecting 118 of 120 residents. Observations revealed dried food debris on oven doors and handles, and the convection oven's control panel. The CDM confirmed the unsanitary conditions, which violated the facility's cleaning policy.
The facility failed to provide a homelike environment during dining, as observed in two dining rooms where residents were served meals on brown plastic trays. Interviews with staff confirmed this practice, which contradicted the facility's policy on creating a homelike atmosphere. The Certified Dietary Manager and Administrator were unaware of the importance of this aspect of meal service.
The facility failed to revise the care plan for a resident receiving enteral feeding, resulting in a discrepancy between the physician's order and the care provided. The resident's care plan was not updated to reflect changes in the feeding rate and water flush volume, as confirmed by the DON and observed during a survey.
The facility failed to provide adequate personal hygiene care for a resident with moderate cognitive impairment, who was observed multiple times with dirty fingernails and facial hair. Despite staff performing regular checks, the resident's hygiene needs were not met, as confirmed by interviews with staff and the resident's daughter.
The facility failed to follow a physician's order to keep a resident's legs elevated to treat edema. Despite the order, the resident was observed multiple times with her legs not elevated, and staff confirmed the lack of compliance.
The facility failed to follow a physician's order for enteral feeding for a resident with a history of severe malnutrition and other health issues. The resident was supposed to receive a water flush of 150 ml every 4 hours but was only receiving 60 ml. This discrepancy was confirmed by nursing staff and the DON, although the resident did not experience any harm.
The facility failed to ensure necessary emergency equipment was available at the bedside for a resident with a tracheostomy. Despite the resident's care plan and physician's orders indicating the need for tracheostomy care and suctioning, the required suction tubing, canister, and ambu bag were not present in the room. This deficiency was confirmed by an LPN and the DON.
The facility failed to properly store medications in one of six medication carts. An LPN was found with mislabeled insulin pens for two residents and a Heparin Lock Syringe stored improperly in an open toothette box. The DON confirmed that the insulin pens should be discarded and new ones ordered, and that the Heparin Lock Syringe should not have been stored with oral care items.
The facility failed to notify the physician in a timely manner regarding abnormal lab results for a resident with multiple diagnoses. A urine specimen collected and sent for analysis showed a urinary tract infection, but the results were not reviewed or communicated to the primary care provider until three days later. The Medical Director and Director of Nursing confirmed the delay.
Incomplete Dialysis Communication Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that dialysis communication records were fully completed for two residents who required dialysis services. According to the facility's contract and policy, staff are responsible for maintaining complete records and ensuring ongoing communication and coordination with dialysis providers. For both residents, who had significant medical histories including end-stage renal disease, diabetes, and other chronic conditions, the PRE/POST DIALYSIS COMMUNICATION forms were found to be incomplete on multiple occasions. Missing documentation included vital information such as pre- and post-dialysis weights, vital signs, changes at the dialysis access site, and staff signatures. Medical record reviews showed that these documentation lapses occurred repeatedly over the course of a month for both residents, despite facility policies requiring thorough completion of these forms. During an interview, the DON confirmed that the forms were not completed in their entirety as required. The incomplete records were directly observed in the residents' files, and the deficiency was acknowledged by facility leadership.
Failure to Accurately Complete MDS Assessment for Dialysis Treatment
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident who was admitted with multiple diagnoses, including End Stage Renal Disease (ESRD), Chronic Obstructive Pulmonary Disease, Diabetes, Vascular Dementia, and mobility issues. Medical records and the Medication Administration Record (MAR) indicated that the resident was ordered and received hemodialysis treatments on specific days following admission. The resident's comprehensive care plan also documented dialysis related to ESRD. However, the admission MDS assessment did not reflect that the resident received dialysis treatments while at the facility. This discrepancy was confirmed by the Clinical Reimbursement Specialist during a review of the medical record and the MDS assessment.
Failure to Develop Comprehensive Care Plan for Resident with Permacath and EBP Needs
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan for one resident who was admitted with multiple complex medical conditions, including Type 2 Diabetes Mellitus, Chronic Respiratory Failure with Hypoxia, Congestive Heart Failure, End Stage Renal Disease, and Muscle Weakness. The resident had a permacath inserted in the right chest for dialysis treatment, which was documented in the nursing admission assessment. Facility policy required the development and implementation of a comprehensive care plan for each resident, including measurable objectives to address all identified medical and nursing needs. Despite these requirements, review of the resident's comprehensive care plan revealed that it did not address the presence of the permacath or the need for Enhanced Barrier Precautions (EBP), both of which were indicated by facility policy for residents with indwelling medical devices. The resident was observed with a clean and dry permacath site, and received dialysis three times per week. The DON confirmed that the care plan should have included the vascular access and EBP, and acknowledged that the facility failed to do so for this resident.
Expired IV Medications Found in Medication Storage Room
Penalty
Summary
The facility failed to ensure that expired intravenous (IV) medications were discarded and not available for resident use, as required by facility policy and professional standards. During an observation in one of the medication storage rooms, surveyors found thirty-one syringes of Heparin lock flush with expiration dates that had already passed. Both the Staff Development Coordinator and the Director of Nursing confirmed that these expired IV medications were present and accessible for use, and acknowledged that such medications should have been discarded according to the expiration date listed on the syringes. The facility's policy specifies that licensed nurses are responsible for checking expiration dates, but this process was not followed, resulting in expired medications being available in the medication storage area.
Failure to Provide Ordered Assistive Eating Device
Penalty
Summary
The facility failed to provide a required assistive meal device, specifically a divided plate, for a resident with significant medical needs. The resident had a history of metabolic encephalopathy, malnutrition, dysphagia, and cognitive communication deficit, and was assessed as cognitively impaired. Medical records, care plans, and a communication order all indicated that the resident required a divided plate at every meal to support independent eating. The resident's meal information card also specified the need for a divided plate. Despite these documented requirements, observations on two separate occasions showed that the resident was served meals on a regular plate rather than the prescribed divided plate. Staff interviews confirmed that the resident needed the divided plate to promote independence with meals, and facility leadership acknowledged that the assistive device was not provided as ordered during the observed meals.
Failure to Remove Expired Food from Resident Refrigerator
Penalty
Summary
Facility staff failed to follow the established policy regarding the weekly inspection and removal of expired food items from residents' personal refrigerators. According to the facility's policy, staff are required to check individual food items in residents' refrigerators weekly and promptly discard any expired items. During an observation, three unopened nutritional shakes with an expiration date of 9/26/2022 were found in a resident's personal refrigerator, indicating that the required weekly checks were not performed as outlined in the policy. The resident involved had multiple diagnoses, including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Right Heart Failure, Alzheimer's Disease, and Dementia, and was assessed as having moderate cognitive impairment. Interviews with staff revealed uncertainty about who was responsible for checking the refrigerators, with the LPN unsure of the process and the DON stating that housekeeping was primarily responsible for weekly checks. The DON confirmed that the expired nutritional shakes should have been discarded according to facility policy.
Inaccurate Documentation of Dialysis Access Site Assessments
Penalty
Summary
The facility failed to ensure that the medical record for a resident receiving dialysis was complete and accurate, specifically regarding documentation of dialysis access site assessments. The resident was admitted with diagnoses including dependence on renal dialysis and end stage renal disease, and had a permacath in the right upper chest for dialysis access. Facility policy required accurate recordkeeping, and physician orders directed staff to assess the dialysis access site for thrill, bruit, and bleeding every shift. However, review of the Medication Administration Record (MAR) showed that LPNs documented assessments of a 'shunt site' for thrill and bruit, even though the resident did not have a shunt but rather a permacath. Interviews with the LPNs revealed that they were aware the resident's dialysis access was a permacath and that they assessed the site for signs of bleeding and infection, but they failed to accurately document these assessments in the MAR, instead recording assessments for a shunt site. The Director of Nursing confirmed that the documentation did not accurately reflect the assessments performed on the resident's actual dialysis access site during the specified period.
Deficiencies in Hand Hygiene, PPE Use, and Sanitary Practices During Meal Service
Penalty
Summary
The facility failed to provide hand hygiene assistance prior to meals for three residents on one of four units observed during meal tray distribution. Specifically, staff delivered meal trays to residents who required assistance or supervision with activities of daily living, including eating and personal hygiene, without offering hand sanitizer or assisting them to wash their hands. Staff interviews confirmed that hand hygiene should have been offered, but was not provided to these residents before meals. Additionally, the facility did not ensure proper use of Personal Protective Equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP) due to a feeding tube. During a high-contact care activity involving the management of a feeding tube, a registered nurse wore gloves but did not don a gown as required by facility policy and posted signage. There was also a lack of appropriate signage indicating the need for EBP at the time of the observation, and staff were not initially aware of the correct PPE requirements for this resident. The facility also failed to maintain sanitary conditions during meal service related to the handling and storage of the ice scoop used for resident drinks. A certified nursing assistant placed the ice scoop directly into the ice storage container instead of the designated holder, preventing the container lid from closing and exposing the ice to potential contamination. Staff interviews confirmed the improper storage of the ice scoop and acknowledged the failure to follow facility procedures for maintaining a sanitary environment.
Failure to Maintain Sanitary Kitchen Equipment
Penalty
Summary
The facility failed to maintain sanitary kitchen equipment, which had the potential to affect 118 of 120 residents. During an initial kitchen observation, the Certified Dietary Manager (CDM) noted a thin layer of dried brown/black food debris on top of both oven doors and on the handle of the left oven door. Additionally, the convection oven had multiple spatters of dried brown food debris on the front control panel. The CDM confirmed the unsanitary condition of the equipment during an interview. The facility's policy, revised on 12/17/2021, mandates that the Director of Food and Nutrition Services develop a cleaning schedule to ensure cleanliness and sanitation at all times, which was not adhered to in this instance.
Failure to Provide a Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike environment during dining in two of the four dining rooms observed. During an observation, it was noted that Certified Nursing Assistants (CNAs) and the Activities Director (AD) delivered meal trays to residents, leaving the dishes of food, beverages, and silverware on brown plastic trays on the tables. Interviews with CNA #2, CNA #3, and the AD confirmed that it was typical for meals to be left on the trays, as it was believed to make it easier for the residents. This practice was observed in both the main dining room and the 100 hall day room, where residents ate their meals directly from the trays and consumed milk directly from the cartons. The facility's policy on Resident Dining Services, revised on 4/26/23, indicated that food should be served in a safe, clean, and homelike environment, which was not adhered to in these instances. Further interviews with the Certified Dietary Manager (CDM) and the Administrator revealed a lack of awareness and discussion regarding the importance of a homelike atmosphere during meal service. The CDM stated that meals had always been served on trays and did not recall any discussions about creating a homelike environment. The Administrator also indicated that he would need to review the facility's policy on dining and meal service before commenting on the practice of leaving food on trays. These findings highlight a systemic issue in the facility's approach to dining services, failing to align with their policy and the residents' right to a homelike environment.
Failure to Revise Enteral Feeding Care Plan
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident who was receiving enteral feeding. The resident, who had a history of malignant neoplasm of the larynx, chronic obstructive pulmonary disease, and dysphagia, was admitted with a care plan that included specific instructions for enteral feeding. However, the care plan was not updated to reflect a physician's order change, which specified a different rate and volume for the feeding and water flushes. This discrepancy was observed during a survey, where the resident was receiving Jevity 1.5 at 60 ml/hour with a water flush of 60 ml every 4 hours, contrary to the physician's order of 60 ml/hour with a 150 ml water flush every 4 hours. Interviews with the LPN and the DON confirmed that the care plan had not been revised to match the updated physician's order. The LPN described the procedure she followed when administering tube feeding, which included checking the resident's order and the PEG site, but the care plan still reflected outdated instructions. The DON acknowledged that it was her expectation for staff to follow the physician's orders and confirmed that the care plan should have been revised to reflect the changes in the enteral feeding instructions.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care for Resident #62, who had moderate cognitive impairment and required limited assistance for dressing, toileting, and personal hygiene. Despite the facility's policy mandating care and services for bathing, dressing, grooming, and oral care, Resident #62 was observed multiple times with dirty fingernails and facial hair on her chin. The resident's fingernails had a brown substance caked under them, and facial hair was present on her chin during observations on 2/26/2024 and 2/27/2024. Interviews with staff and the resident's daughter confirmed the lack of proper hygiene care. CNA #1 stated that she performed incontinence and general cleanliness checks every two hours, yet the resident's fingernails remained dirty. The Director of Nursing (DON) acknowledged that staff were expected to keep residents' fingernails clean and remove facial hair from female residents. Despite these expectations, the facility failed to meet the hygiene needs of Resident #62, as evidenced by the repeated observations of dirty fingernails and facial hair.
Failure to Follow Physician's Order for Edema Treatment
Penalty
Summary
The facility failed to follow a physician's order for the treatment of edema for one resident. Resident #21, who has severe cognitive impairment and uses a wheelchair for ambulation, was observed multiple times with her legs not elevated as per the physician's order dated 4/9/2023. The order specified that the resident's legs should be kept elevated when out of bed every shift. However, during observations on 2/27/2024 and 2/28/2024, the resident was seen with her legs hanging down and feet on the floor, both in her room and in the day room. Licensed Practical Nurse (LPN) #6 and the Director of Nursing (DON) confirmed that the resident's legs were not elevated and that there was no equipment on the specialized wheelchair to facilitate leg elevation. The DON acknowledged that the staff was not following the physician's orders, as it was her expectation for the staff to adhere to the prescribed treatment plan. This failure to follow the physician's order was identified during the review of the facility policy, medical records, and through direct observation and interviews with the staff.
Failure to Follow Physician's Order for Enteral Feeding
Penalty
Summary
The facility failed to follow a physician's order for enteral feeding for Resident #79. The resident, who had a history of malignant neoplasm of the larynx, chronic obstructive pulmonary disease, and dysphagia, was admitted with a care plan indicating a risk for weight fluctuation and severe malnutrition. The physician's order specified that the resident should receive Jevity 1.5 at 60 ml/hour for 22 hours with a water flush of 150 ml every 4 hours. However, observations on multiple occasions revealed that the resident was receiving a water flush of only 60 ml every 4 hours, contrary to the physician's order. This discrepancy was confirmed by RN #1 and the Director of Nursing (DON), who acknowledged that the nursing staff had not adhered to the prescribed orders for tube feeding. During an interview, the Medical Doctor confirmed that the resident had not experienced any harm, dehydration, or associated symptoms due to the incorrect water flush rate. The resident remained at baseline with no hypotensive episodes. Despite this, the failure to follow the physician's order for enteral feeding represents a deficiency in the facility's adherence to proper medication administration protocols, as outlined in their policy dated 8/24/2023.
Failure to Provide Necessary Emergency Equipment for Tracheostomy Care
Penalty
Summary
The facility failed to ensure necessary emergency equipment was immediately available at the bedside for a resident with a tracheostomy. The facility's policy required that each resident with a tracheostomy have emergency supplies, including a manual resuscitator and mask (ambu bag) and suction equipment, at the bedside. However, during an observation, it was noted that Resident #79, who had a tracheostomy, did not have the complete suction tubing, canister, or ambu bag in the room. This was confirmed by an LPN and the Director of Nursing (DON), who acknowledged that the required emergency supplies were not available at the bedside. Resident #79 was admitted with diagnoses including a personal history of malignant neoplasm of the larynx, chronic obstructive pulmonary disease, and dysphagia. The resident's care plan and physician's orders indicated the need for tracheostomy care and suctioning as necessary. Despite these requirements, the necessary emergency equipment was not present in the resident's room during the surveyor's observation, leading to a deficiency in providing safe and appropriate respiratory care for the resident.
Improper Medication Storage
Penalty
Summary
The facility failed to properly store medications in one of six medication carts. During an observation, an LPN was found to have an insulin pen for Resident #39 in a plastic bag with a prescription label, but the pen itself also had a label for Resident #105. Additionally, Resident #105's insulin pen did not have a label on it. The LPN acknowledged the issue and stated she would report it to her supervisor. Further inspection of the cart revealed a Heparin Lock Syringe stored improperly in an open toothette box, which the LPN also acknowledged as incorrect storage. In a telephone interview, another LPN confirmed that she administered insulin to both residents and checked the insulin pen against the Medication Administration Record (MAR) and the label to ensure they matched. The Director of Nursing (DON) stated that the insulin pens should be discarded and new ones ordered, and confirmed that the Heparin Lock Syringe should not have been stored with oral care items. The facility's policy mandates that external use medications and biologicals be stored separately from internal use medications and biologicals, which was not followed in this instance.
Delayed Notification of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding abnormal laboratory results for one resident. Resident #39, who had multiple diagnoses including Chronic Obstructive Pulmonary Disease, Vascular Dementia, Type 2 Diabetes Mellitus, Hypertension, Hemiplegia and Hemiparesis, Repeated Falls, and Adult Failure to Thrive, was admitted to the facility. A urine specimen was collected on 2/18/2024 and sent for urinalysis, culture, and sensitivity. The results, received on 2/23/2024, indicated a urinary tract infection, but there was no documentation that a provider had reviewed the report on the same day it was received. On 2/26/2024, an LPN discovered that the report had not been sent to the primary care provider and subsequently notified the Nurse Practitioner, who then ordered an antibiotic. The Medical Director confirmed that there was no negative outcome for the resident due to the delay, but expressed that he would have expected to be notified of the results on the day they were received. The Director of Nursing confirmed that the notification of the abnormal lab result to the physician or nurse practitioner was delayed by three days.
Latest citations in Tennessee
Surveyors found that staff did not follow the facility’s infection prevention policies, including Enhanced Barrier Precautions (EBP), hand hygiene, and urinary catheter management. A respiratory therapist performed trach care and suctioning for two residents with tracheostomies without donning required gowns or masks, placed supplies and an inner cannula on the resident’s abdomen and linens, and left a room wearing contaminated gloves. An RN administered meds via a feeding tube for a resident with a gastrostomy, then performed eyelid scrubs without changing gloves or performing hand hygiene between routes of care and without using a gown despite EBP signage. CNAs delivered and set up lunch trays for three residents who required at least some assistance with hygiene or meals but did not offer hand hygiene before eating, contrary to policy. In addition, a resident with a urinary catheter was observed in bed with the drainage bag lying on the floor, rather than suspended from the bed as confirmed by nursing staff and the IP.
Administration allowed an unqualified individual to be hired and work as an LPN by failing to verify licensure and reconcile name discrepancies across hiring documents. The individual’s I-9, birth certificate, and out-of-state driver’s license reflected one last name, while the TN LPN license verification on file belonged to a different nurse with the same first name but a different last name. Abuse registry checks were completed under both names, but no national background check or documentation explaining the differing names was present. The person was offered a temporary/contract LPN position, worked multiple shifts, and had conflicting separation notices, with no documentation of a formal rehire. The HR Director confirmed there was no hiring policy and that the individual worked onsite as an LPN before being terminated for failure to attend or complete training.
Administration failed to ensure nursing services were provided by qualified personnel when an unlicensed individual was hired and allowed to work as an RN and Unit Manager using another nurse’s license. Pre-employment documents for this staff member contained inconsistent SSNs and birth dates across the application, background check, W-4, and I-9, and the background report noted the SSN could not be validated. No abuse registry check or RN license verification was completed before hire, and a later license verification showed the last name on the RN license did not match the individual’s last name. The imposter, a walk-in applicant without a resume, worked multiple shifts providing nursing services before being separated as a voluntary termination, and facility staff did not question the documented discrepancies.
Administration allowed an unlicensed individual to be hired twice and function as an LPN using another LPN’s Tennessee license. During the first hire, conflicting SSNs appeared on the application and tax forms, the I‑9 identified the imposter by her own name and out‑of‑state driver’s license, and the license verification was for a different nurse with only the same first name; no Tennessee Abuse Registry check was documented, and the imposter worked multiple shifts before resigning. During the second hire, a different SSN was used, no I‑9 or supporting identity documents were on file, and the same other nurse’s license was again used for verification; the imposter worked several days before resigning. The Administrator reported that the same resume was used for both hires and that the facility had no formal hiring policy, only a checklist.
Administration failed to ensure nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s license. The facility’s own employment policy requiring HR completion of I-9 Section 2, consistent SSN use, and verification of license and abuse registry status was not followed. The imposter’s application and background check contained conflicting SSNs, names, and birthdates, and the I-9 was not signed by HR. An abuse registry check was run only on one SSN, and discrepancies were not investigated. Time records showed the imposter worked several shifts and had patient access, while leadership later confirmed she remained on the books until being treated as a voluntary termination for not picking up shifts.
Administration failed to ensure nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN under another nurse’s license. Facility records showed multiple unexplained discrepancies in the individual’s name, SSN, and birthdate across the background check, I-9, W-4, Consumer Information Sheet, and separation notice, and the I-9 was never completed or signed by facility staff. Time records confirmed the imposter worked several shifts as an RN before being terminated for no call/no show, and an abuse registry check was not completed until long after termination. The facility did not produce hiring policies or documentation that anyone questioned the conflicting identification information before or during this person’s employment.
Staff failed to honor a resident’s right to refuse care when CNAs proceeded with a scheduled shower despite the resident verbally declining. The resident, who had severe dementia with agitation and was dependent on staff for bathing, had a care plan directing staff to discuss objections, inform of risks, offer choices, and accept refusals. Instead, after the resident said they did not want a shower, one CNA pulled off the covers, and the CNAs placed the resident in a shower chair and continued with the shower because it was the resident’s assigned shower day, contrary to facility policy and the care plan.
A resident with severe cognitive impairment and multiple comorbidities was admitted for rehab and had clearly documented full code status in the face sheet, care plan, and physician orders. During the night, the resident was last observed awake and later found unresponsive with no heart sounds, pulse, or respirations. Staff initiated CPR and continued until the resident was pronounced deceased, but the record contained no evidence that EMS/911 was contacted or that an AED was obtained or used, despite facility policy and leadership expectations that full code residents receive CPR with 911 activation and AED use, and despite the presence of two AEDs in the facility.
A resident with severe cognitive impairment, type 2 DM, CKD, and a history of falls had physician orders for blood glucose checks before meals and at bedtime and for sliding scale insulin aspart four times daily. Facility policy required verification of insulin orders, blood glucose monitoring per orders, and documentation of results and doses. However, after an NP attempted to edit the sliding scale order in the EHR, the order remained unsigned and inactive in the queue, preventing it from appearing on the MAR. Nursing staff did not identify that the insulin order was missing, resulting in multiple missed blood glucose checks and insulin doses over several days, despite the resident’s care plan directing staff to follow physician orders for diabetes management.
The facility failed to maintain a clean and sanitary environment in multiple resident rooms and bathrooms, despite policies requiring routine cleaning and disinfection. Observations over several days found a motorized wheelchair and another wheelchair with attached cushion soiled with dried, multi-colored debris. Several resident bathrooms had unclean conditions, including a trash can without a liner and with dried brown residue, toilets with dried yellow residue on the seats, and yellow/orange or brown substances around the bases of multiple toilets. During an on-site check, the Administrator confirmed that the residue around one toilet could be wiped away and that the area was not clean.
Failure to Follow EBP, Hand Hygiene, and Catheter Practices During Respiratory, Enteral, and Daily Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies, including Enhanced Barrier Precautions (EBP), hand hygiene, and urinary catheter management. The facility’s EBP policy required staff to perform hand hygiene, review EBP signage, and don gown and gloves prior to high-contact resident care activities such as tracheostomy care, suctioning, and device care, then remove PPE and perform hand hygiene before leaving the resident’s room. For Resident #1, who had epilepsy, acute on chronic respiratory failure, a tracheostomy, and ventilator dependence, a respiratory therapist entered the room where EBP signage was posted, used pocket hand sanitizer, and donned gloves but did not don a gown or mask. The therapist placed clean gauze and used split gauze directly on the resident’s abdomen, allowed the tracheostomy inner cannula to roll from the abdomen onto the linens, and then left the room carrying a box while still wearing the same contaminated gloves, only discarding them later at the respiratory therapy cart. The therapist acknowledged not setting up supplies appropriately, not discarding gloves and performing hand hygiene before leaving the room, and not following EBP, stating she believed EBP was only required for residents with an active infection. For Resident #8, who had traumatic brain injury, quadriplegia, acute respiratory failure, and a tracheostomy, the same respiratory therapist again entered a room with EBP signage and donned gloves but no gown or mask before performing tracheal suctioning using an in-line suction catheter. The resident had reflex coughing during suctioning. After completing suctioning, the therapist discarded gloves and used pocket hand sanitizer but again did not follow the full EBP requirements. The infection preventionist later confirmed that EBP was required for high-contact care such as tracheal care and suctioning, and that gloves should be discarded before leaving the room with hand hygiene performed each time gloves are removed. The facility also failed to follow EBP and hand hygiene practices during medication administration for Resident #22, who had chronic respiratory failure, quadriplegia, tracheostomy status, and gastrostomy status, and who had long- and short-term memory deficits with severely impaired decision-making. A registered nurse entered the resident’s room, where EBP signage was posted, donned gloves but not a gown, and administered medications via the gastrostomy tube using a piston syringe, flushing with water as ordered. With the same used gloves still on, the nurse rinsed the piston syringe in the room sink, set it on paper towels to dry, and then performed OcuSoft eyelid scrubs to both eyes without changing gloves or performing hand hygiene between the different routes of care. The nurse confirmed she did not don a gown and did not perform hand hygiene or change gloves between the feeding tube medication administration and the eye care, and the infection preventionist confirmed that EBP and hand hygiene with glove changes were expected between administering medications by different routes. Additional deficiencies were identified in hand hygiene assistance before meals and urinary catheter management. The facility’s resident handwashing policy required staff to offer hand hygiene before meals. Resident #47, who had acute and chronic respiratory failure, epilepsy, atrial fibrillation, and chronic pulmonary edema and was dependent for hygiene and feeding assistance, received a lunch tray from a CNA who set up the tray and left without offering hand hygiene assistance. Resident #31, with COPD, acute and chronic respiratory failure, morbid obesity, and a care plan indicating partial to moderate assistance with hygiene, also had a lunch tray delivered and set up by a CNA who exited without offering hand hygiene. Resident #66, with COPD, chronic respiratory failure, generalized muscle weakness, and substantial to maximal ADL needs including meal assistance, likewise had a lunch tray delivered and set up without being offered hand hygiene. One CNA acknowledged residents were to be offered hand hygiene before meals, and another stated she had not offered hand hygiene unless residents mentioned it. The infection preventionist confirmed staff were expected to offer hand hygiene assistance to all residents prior to meals. The facility further failed to maintain proper urinary catheter bag positioning for Resident #15, who had chronic osteomyelitis, depression, anxiety, paraplegia, and required assistance with ADLs, including urinary catheter care per orders and protocol. During observation, the resident was in bed with the urinary catheter drainage bag lying on the floor beside the bed. A licensed practical nurse confirmed the catheter bag should be hung from the bed, and the infection preventionist confirmed catheter bags were to be suspended off the ground to prevent infection. These observations demonstrated non-adherence to the facility’s infection prevention and control practices related to EBP, hand hygiene, and catheter management across multiple residents and care situations.
Imposter Hired and Employed as LPN Without Proper License Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an LPN using another nurse’s Tennessee license. Personnel file review showed that the individual, referred to as Imposter Nurse A, had an I-9 form completed with her legal first and last name, supported by a birth certificate and an out-of-state driver’s license, and a Tennessee Criminal History Record Request indicating no Tennessee criminal history under that name. However, the nursing license verification in the file was for a different person, an LPN with the same first name but a different last name (LPN C). Two Tennessee Abuse Registry checks were present, one under LPN C’s name and one under Imposter Nurse A’s name, but there was no documentation explaining or reconciling the name discrepancies between the I-9, the license verification, and other employment documents. There was also no national background check in the personnel file. The facility issued an offer letter to Imposter Nurse A for a temporary/contract LPN position, and time sheets showed she worked multiple shifts on several dates. Two separation notices documented voluntary separation without notice, with differing last days worked, and there was no paperwork provided to explain her apparent rehire after the first termination. During interview, the Human Resource Director acknowledged there was no hiring policy, confirmed that Imposter Nurse A worked onsite as an LPN, and stated she was terminated for failure to attend or complete training and for failure to come in as needed. No information was provided to surveyors showing any cross-check or investigation of the inconsistent names across the employment application, I-9 form, and nursing license verification, resulting in the facility employing an unqualified person in an LPN role.
Imposter RN Hired and Allowed to Function Without Proper Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s Tennessee license. Facility policy titled “Abuse Program Policy” required pre-employment screening, including obtaining a copy of the state license for licensed positions and completing a criminal background check per state statute. The application for employment for the imposter nurse contained a scratched-out Social Security Number (SSN) with a different SSN written above that did not match the SSN on the I-9 form, and the birth date on the application also did not match the I-9. The background screening report showed an SSN and birth date that did not match the I-9 and included a note stating “UNABLE TO VALIDATE SSN.” A W-4 form contained an SSN that did not match the background check. The I-9 form listed the imposter’s legal first and last name, with a Social Security card and valid Tennessee driver’s license, but the birth date on the I-9 differed from the birth date on the background check. Review of the personnel file revealed no evidence that an abuse registry check was completed prior to hire, and there was no evidence that a license verification was done before the imposter nurse’s start date. Time cards showed the imposter worked multiple days in February and March as a Unit Manager. A later QuickConfirm license verification showed that the last name on the validated RN license did not match the imposter’s last name. Interviews with the DON, HR representative, and Administrator confirmed that the imposter was a walk-in applicant who did not provide a resume, that in-house HR was responsible for ordering background checks with corporate as backup, and that the imposter worked in the facility as a Unit Manager and was only separated as a voluntary termination for inability to uphold weekend schedule obligations. There was no evidence that the facility questioned the discrepancies in names, birth dates, or SSNs on the pre-employment documents, resulting in the employment of an unqualified person to render nursing services as an RN.
Imposter Nurse Hired Twice and Allowed to Function as LPN Without Proper Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and allowed to function as an LPN on two separate occasions using another nurse’s Tennessee license. For the first hire, the personnel file showed an employment application dated 02/08/2023 with a Social Security Number (SSN) that did not match the SSN on the W‑4 form dated 02/13/2023. The I‑9 form dated 02/13/2023 listed the imposter’s legal first and last name, supported by a birth certificate and an out‑of‑state driver’s license, and the last name on the I‑9 matched the driver’s license. However, the license verification form in the file was for a different individual, an LPN with the same first name but a different last name, and there was no evidence that a Tennessee Abuse Registry check was completed prior to the 02/13/2023 hire date. Time punch records showed the imposter worked multiple shifts in February, March, April, and May 2023 before being terminated on 06/06/2023, with the termination form citing voluntary resignation due to chronic absenteeism and tardiness. For the second hire, the imposter was rehired with a personnel file showing that the SSN on the employment application, W‑4, and background check matched each other but differed from the two SSNs used during the first hire, meaning three different SSNs were used across the two employment periods. There was no I‑9 form or supporting identity documents in the file for the rehire. A license verification form again showed a nursing license in the name of the same LPN whose license had been used previously, with the same first name as the imposter but a different last name and a later expiration date. The background screening report dated 02/13/2024 used the SSN from the employee application, which did not match the SSN previously submitted on the I‑9 form from the first hire. Time punch data showed the imposter worked several days in May 2024 before a termination dated 06/24/2024, which documented voluntary resignation after failing to provide a schedule and not returning after orientation. In an interview, the Administrator stated the facility used the same resume for both hires and that the facility did not have a hiring policy, only a checklist.
Imposter RN Hired and Allowed to Work Without Proper License Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s Tennessee RN license. The facility’s Employment policy required the HR Director to complete Section 2 of the I-9, conduct background investigations, and verify licenses and abuse registry status using the applicant’s registration or Social Security number. Review of the imposter’s employment application showed a Social Security number scratched out and replaced with another number that did not match the SSN used on the background check. The background check listed both the imposter’s name and the legitimate RN’s name, and it showed the legitimate RN’s license number. The birthdate on the I-9 did not match the birthdate on the background check, and Section 2 of the I-9 was not signed by the HR Director as required by policy. Further review showed that an abuse registry search was completed using the SSN from the Social Security card submitted with the I-9, but no search was conducted using the SSN listed on the background check. The separation notice for the imposter listed her real first and last name with an SSN that again did not match the SSN on the background check, and documented employment from mid-June to late November with the reason for termination as voluntary due to not picking up shifts for over three months. Employee time entries showed the imposter worked multiple days in June and one day in July. The DON confirmed that the imposter used an online artificial intelligence website for charting and stated the imposter had access to patients for one day in July. The Administrator confirmed the imposter was considered employed during the stated period and was not formally fired or documented as having quit. There was no evidence that the facility questioned the discrepancies in names, birthdates, or Social Security numbers on the pre-employment documents, resulting in the employment of an unqualified person as an RN.
Imposter RN Hired and Allowed to Work Despite Multiple Identification Discrepancies
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s Tennessee license. Personnel file and document review showed multiple inconsistencies in the imposter nurse’s identifying information that were not questioned by the facility. The background check dated 06/14/2024 used a Social Security Number (SSN) that did not match the SSN on the Social Security card submitted. The I-9 form dated 06/15/2024 listed the imposter’s legal first and last name, with a copy of her Social Security card and a valid Tennessee driver’s license, but the SSN on the I-9 did not match the SSN on the Social Security card. The I-9 form was not completed, signed, or dated by any facility representative. Time punch data showed the imposter nurse worked multiple days in June and July 2024. A separation notice dated 07/31/2024 listed the imposter’s real first and last name with an SSN that did not match the SSN on the I-9 form, and documented employment dates from 06/12/2024 to 07/31/2024 with termination for no call/no show. An undated Consumer Information Sheet listed the imposter’s first and last name with the legitimate RN’s last name as her middle name, a birth year that did not match the I-9, and an SSN that did not match the SSN on the W-4 form or the separation notice. The abuse registry check for the imposter was not completed until 08/04/2025, after termination. The facility did not provide any hiring policies and there was no evidence that staff questioned the discrepancies in names, birth dates, or SSNs on the pre-employment forms, resulting in the employment of an unqualified person as an RN.
Failure to Honor Resident’s Refusal of Shower and Right to Self-Determination
Penalty
Summary
The deficiency involves staff failure to honor a resident’s right to self-determination and refusal of treatment, specifically related to bathing. Facility policy on Resident Rights and Responsibilities states that residents have the right to refuse treatment and to be informed of the medical consequences of such refusal, and to exercise their rights without discrimination or reprisal. Resident #31, admitted in late 2023, had severe dementia with agitation, a BIMS score of 3 indicating severe cognitive impairment, and was dependent on staff for showering and personal hygiene. The resident’s care plan identified behavior problems and resistance to care related to dementia, knowledge deficit, denial of illness and risk factors, and mental/emotional illness, with interventions directing staff to discuss objections and fears, inform the resident of risks of non-compliance, offer choices, and accept and respect the resident’s right to refuse care. Despite these policies and care plan interventions, staff proceeded with a shower after the resident refused. A CNA assigned to the resident reported that the resident had refused a shower, and another CNA responded that it was the resident’s shower day and that the shower should be provided. According to written statements, when the CNAs entered the room and informed the resident it was shower day, the resident stated, “No I don’t want a shower.” One CNA then told the resident they were getting a shower and pulled the covers off the resident. The CNAs placed the resident in a shower chair and continued with the shower despite the expressed refusal. During a later interview, the CNA confirmed instructing the other staff member to go ahead and provide the shower because it was the resident’s scheduled shower day, demonstrating that the resident’s right to refuse care and the care plan interventions to respect refusals were not followed.
Failure to Contact EMS and Use AED During CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its CPR and emergency response policy for a resident who was a documented full code. Facility policy required staff to call 911 for resident emergencies, obtain and use an AED, and initiate CPR for full code residents unless there was a POST form or other physician order to withhold CPR, or the resident showed American Heart Association (AHA) signs of clinical death. The 2020 AHA Adult Basic Life Support Algorithm directs healthcare providers to activate the emergency response system, obtain an AED, and use it as soon as available when a person has no breathing or only gasping and no pulse. The facility had two AEDs and staff were educated on AED use as part of CPR training. Resident #78 was admitted for rehabilitation and 24-hour skilled nursing care following a hospitalization due to a fall at home and had a medical history including atrial fibrillation with multiple cardioversions, dysphagia, chronic kidney disease, mild cognitive impairment with memory loss, hypertension, UTI, influenza, and type 2 diabetes mellitus. The resident’s profile, care plan, and physician’s orders all documented full code status. A 5-day MDS showed a BIMS score of 4, indicating severe cognitive impairment. On the evening prior to the event, an RN documented that the resident was sitting in a wheelchair watching television at 8:20 PM, was assisted to the bathroom at 10:00 PM, and was checked again at 12:00 AM. At approximately 2:00 AM, a CNA found the resident unresponsive and notified the RN, who assessed the resident and documented no heart sounds, pulse, or respirations. Staff initiated CPR and continued efforts until the RN pronounced the resident deceased at 2:45 AM. There was no documentation in the medical record that EMS/911 was contacted or that an AED was used during the resuscitation attempt, despite facility policy and the expectations stated by the DON, LPN, NP, and Medical Director that staff should call 911, obtain and use an AED, and continue CPR until EMS arrival for a full code resident. An email from the local fire department indicated there were no EMS reports for the resident on the date in question, and the DON stated she had no evidence to verify that EMS was contacted and no AED log to show whether an AED was used. The Administrator stated she expected staff to follow the CPR policy and properly document all care and services provided, but the record lacked evidence of EMS notification or AED utilization for this full code resident.
Failure to Activate and Follow Sliding Scale Insulin and Blood Glucose Orders
Penalty
Summary
The deficiency involves the facility’s failure to activate and carry out physician orders for blood glucose monitoring and sliding scale insulin for a resident with type 2 diabetes. Facility policy on insulin administration required verification that insulin type, dosage, strength, and method of administration corresponded with the physician’s order, checking blood glucose per physician order or facility protocol, and documenting blood glucose results and insulin doses. The resident’s care plan for diabetes directed staff to check blood sugar levels via fingerstick per physician orders and to administer medications per physician orders. The resident was admitted for rehabilitation and 24-hour skilled nursing care following a hospitalization due to a fall at home and had a medical history that included chronic kidney disease and type 2 diabetes mellitus. A 5-day MDS showed severe cognitive impairment with a BIMS score of 4 and an active diagnosis of type 2 diabetes, with insulin injections received. Physician orders directed staff to check the resident’s blood sugar before meals and at bedtime, four times a day, and to administer insulin aspart via a sliding scale four times a day. These orders were in place with a specified stop date and then renewed. Despite these orders, the medication record for the resident showed no documentation of blood sugar levels or administration of insulin aspart at multiple ordered times over several days. A family member reported concern that the resident’s blood sugar levels had not been checked for the past couple of days and that the resident was not on a short-acting insulin. A medication error report later identified that the NP had updated the sliding scale insulin order, but the update was not signed and remained in the unsigned order queue, leaving the insulin aspart order inactive on the MAR. As a result, nursing staff could not see the updated order and missed multiple doses of insulin aspart. The NP stated that she had intended to edit, not discontinue, the sliding scale order, but the electronic medical record required her to unsign the order to edit it, and she failed to reactivate it. The DON stated that nursing staff failed to identify that the insulin aspart order was missing and remained in the queue awaiting reactivation, and the Administrator stated that her expectation was for staff to follow company policy and for the DON or designee to verify that all active orders were visible for nurses when a plan of correction for missing insulin doses had been implemented. A physician statement documented that the resident had uncontrolled type 2 diabetes mellitus, CKD stage III, and hyperlipidemia, and that the resident received sliding scale insulin on one day but did not receive any sliding scale insulin on the following two days. The physician noted that the resident’s blood glucose reached a maximum level of 343 mg/dL during this period and that the sliding scale insulin order was later replaced and resumed. These findings collectively show that the facility did not provide treatment and care according to physician orders and the resident’s care plan for diabetes management, due to the failure to activate and monitor the sliding scale insulin and blood glucose orders in the electronic system and to recognize and correct the missing active order on the MAR.
Failure to Maintain Clean and Sanitary Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean and sanitary environment in multiple resident rooms and bathrooms, contrary to its own policies on routine bathroom cleaning and routine cleaning and disinfection. The facility’s policies, dated 6/2025, required providing a clean and sanitary environment, cleaning the entire toilet including the handle and underside of the flush rim with disinfectant and appropriate contact time, and reporting damaged items in need of repair. Observations conducted on several days showed that in one room, a motorized wheelchair had dried debris on the cushion, arms, and a large amount of multi-colored debris on the undercarriage. In another room, a wheelchair with a fabric heel protector cushion used as an armrest was spattered with small to pea-sized unknown multi-colored particles. Additional observations revealed that several resident bathrooms were not maintained in a sanitary condition. One bathroom had a trash can without a bag and with a dried brown substance on the outside, rim, and inside of the can, as well as a toilet seat with two areas of dried yellow residue and a yellow/orange substance around the base of the toilet. Other bathrooms in different rooms had yellow/orange or brown residue around or at the front base of the toilets. During an observation and interview in one of the bathrooms, the Administrator initially suggested the substance around the toilets might be related to the wax ring, but after wiping a small area with a wet wipe, the yellow/orange substance was easily removed, and the Administrator confirmed the area around the toilet was not clean.
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