Holston Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kingsport, Tennessee.
- Location
- 3641 Memorial Blvd, Kingsport, Tennessee 37664
- CMS Provider Number
- 445295
- Inspections on file
- 18
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Holston Rehabilitation And Care Center during CMS and state inspections, most recent first.
The facility failed to maintain sanitary kitchen equipment, specifically the gas stove griddle, which had dried food debris. The Certified Dietary Manager confirmed the unsanitary condition, acknowledging that the equipment required further cleaning. This deficiency had the potential to affect 120 of the 122 residents.
The facility failed to ensure medical information was not visible for three residents and did not assist a resident to the smoking area as per their care plan. Unauthorized signs with residents' full names and medical needs were posted, and staff inconsistently followed the facility's smoking assistance policy.
The facility failed to accurately complete MDS assessments for two residents. One resident was incorrectly documented as edentulous despite having natural teeth, and another resident was inaccurately coded with an active diagnosis of Septicemia, which was not treated in the 7-day look-back period. Interviews and observations confirmed these inaccuracies.
The facility failed to develop and implement person-centered care plans for two residents. One resident's care plan inaccurately documented dental needs, while another resident's care plan did not reflect her spiritual preferences, leading to inappropriate participation in religious activities.
The facility failed to include a resident or the resident's representative in the care planning process. Despite the resident having severe cognitive impairment and a care plan indicating a knowledge deficit, the resident's daughter confirmed she was never invited to a care plan meeting. The Director of Social Services acknowledged that no care plan conference had been held, contrary to the facility's policy.
A resident had unsecured medications, including Tiotropium Bromide and antacid tablets, left at the bedside without an assessment for self-administration. The LPN was unaware of the unsecured medications, and the DON confirmed that the medications should not have been left in the room.
The facility failed to accurately transcribe an admission order for one resident, leading to an incorrect dosage of Prednisone being administered. Additionally, the facility inaccurately documented another resident's dental condition, recording them as edentulous with dentures when they had natural teeth and a broken tooth.
The facility failed to ensure a coordinated hospice plan of care was available in the medical record for a resident with complex medical needs. Despite the facility's policy and contract requirements, staff were unable to locate the hospice plan of care in either the physical or electronic medical records. The Director of Nursing confirmed the deficiency.
The facility failed to assist four residents with hand hygiene before meals on one of the five hallways observed for meal service. Staff, including the Social Services Assistant, Director of Social Services, and a CNA, did not offer or assist residents with hand hygiene before serving lunch meals. Interviews confirmed that staff were either unaware or did not follow the facility's policy requiring hand hygiene before meals.
Unsanitary Kitchen Equipment
Penalty
Summary
The facility failed to maintain sanitary kitchen equipment, specifically the gas stove griddle, which had a layer of dried brownish-black food debris on the top and the right-side lip of the metal splashguard. This was observed during an initial kitchen inspection with the Certified Dietary Manager (CDM), who confirmed that the kitchen equipment was supposed to be cleaned daily and deep cleaned weekly. The CDM acknowledged that the stove griddle was in an unsanitary condition and required further cleaning. This deficiency had the potential to affect 120 of the 122 residents in the facility.
Failure to Maintain Resident Privacy and Assist with Smoking
Penalty
Summary
The facility failed to ensure medical information was not visible for three residents and failed to assist one resident to the smoking area. For Residents #1, #27, and #31, signs were posted above their beds indicating specific care instructions, including their full names and medical needs, without their or their representatives' consent. These signs were visible to anyone entering the room, which was confirmed by LPN #3 and the Director of Nursing (DON). The DON acknowledged that the signage was a dignity concern and confirmed that the residents' care plans did not reflect any requests for such signage. The signs were removed after the surveyors brought them to the facility's attention, but the staff member responsible for posting them was unknown. Resident #47, who had moderate cognitive impairment and was designated as a supervised smoker, reported that CNA #1 refused to assist him to the smoking area multiple times. CNA #1 stated that she was informed by LPN #1 that if a resident could not propel themselves to the smoking area, staff were not to assist them due to safety concerns. However, the LPN could not articulate what those safety concerns were. During an observation, CNA #1 initially refused to assist Resident #47 to the smoking area but later agreed after the resident requested to speak to management. The Administrator and DON stated that it was their expectation for staff to assist residents to the smoking area if needed. The facility's failure to maintain resident privacy and dignity by posting unauthorized medical information and not assisting a resident to the smoking area as per their care plan led to the deficiencies. The DON confirmed that resident care needs should be communicated through care plans and CNA task sheets, not through visible signage in resident rooms. Additionally, the facility's policy on smoking assistance was not consistently followed, leading to confusion and unmet resident needs.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents. Resident #364 was admitted with diagnoses including Malignant Neoplasm of Left Breast, Hypertension, and Osteoporosis. The admission MDS assessment inaccurately documented the resident as edentulous, while observations and interviews revealed that the resident had natural teeth, including a broken tooth. The MDS Coordinator confirmed that the admission Oral Cavity Observation and Clinical Admission assessments were inaccurate, and the quarterly MDS assessment did not reflect the resident's actual dental status. Resident #1 was admitted with diagnoses including Hemiplegia, Asthma, Depression, Dementia, Atrial Fibrillation, Hypertension, and Peripheral Vascular Disease. The quarterly MDS assessment inaccurately documented an active diagnosis of Septicemia. Interviews with the LPN, MDS Coordinator, and DON confirmed that the resident had not been treated for Septicemia in the 7-day look-back period, and the MDS assessment was inaccurately coded. The MDS Coordinator acknowledged the expectation that the MDS assessment should be coded accurately based on the RAI manual.
Failure to Develop Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, leading to deficiencies in their care. Resident #364 was admitted with diagnoses including Malignant Neoplasm of the Left Breast, Hypertension, and Osteoporosis. Despite multiple assessments indicating that Resident #364 had natural teeth and a broken tooth, the comprehensive care plan inaccurately documented the resident as edentulous and requiring denture care. Interviews with the resident, her daughter, and facility staff confirmed the presence of natural teeth and the broken tooth, highlighting the care plan's inaccuracy and lack of person-centered care. Resident #100, admitted with Hemiplegia following a Cerebral Infarction, Aphasia, and Nontraumatic Intracerebral Hemorrhage, had a care plan that did not reflect her spiritual preferences. Despite an initial assessment indicating no preference for spiritual activities or clergy visits, the care plan included a generic spiritual distress problem and the resident was taken to church services against her and her family's wishes. Interviews with the resident's family and facility staff confirmed the discrepancy between the resident's documented preferences and the care plan, demonstrating a failure to provide person-centered care.
Failure to Include Resident or Representative in Care Planning
Penalty
Summary
The facility failed to include the resident or the resident's representative in the care planning process for one resident. According to the facility's policy, a comprehensive person-centered care plan should be developed for each resident, including the participation of the resident and their representative when possible. Resident #106, who was admitted with diagnoses including Type 2 Diabetes Mellitus and Obstructive Sleep Apnea, had a care plan dated 1/26/2024, which indicated a knowledge deficit with an intervention to promote participation in the treatment regimen. However, the resident had severe cognitive impairment, as shown in a 5-day Minimum Data Set (MDS) assessment, and the resident's daughter confirmed she had never been invited to a care plan meeting or had a discussion about her mother's plan of care. During an interview, the Director of Social Services (DSS) confirmed that no care plan conference had been held with Resident #106 or the resident's representative. The DSS stated that care conferences are typically set up by the admissions team within 48 hours, or 72 hours if the admission falls on a weekend. Despite this expectation, the care plan meeting for Resident #106 had not been conducted, leading to the deficiency noted in the report.
Unsecured Medications at Bedside
Penalty
Summary
The facility failed to provide a safe environment by leaving medications unsecured at the bedside for one resident. The facility's policy mandates that medications should be stored in a medication cart or other designated area unless a resident has been assessed and approved for self-administration. Resident #419, who was cognitively intact, had a box of Tiotropium Bromide (Spiriva Handihaler) and a bottle of antacid tablets left unsecured in his room. The resident stated he needed the Tiotropium Bromide refilled and had the box in the room to give his daughter the information. He also brought the antacid tablets from home for his indigestion. These medications were observed to be left out on multiple occasions without any assessment for self-administration being conducted for the resident. During an observation and interview, an LPN confirmed that medications are not supposed to be left in a resident's room and should be locked up. The LPN admitted she was unaware of the full capsule left in the Tiotropium Bromide box and had not noticed the antacid tablets. The medications were subsequently removed and locked up. The DON stated that the nurses should have educated the resident about not storing medications in the room and should have removed the medications if the resident refused to comply. The DON confirmed that the medications should not have been left in the resident's room.
Inaccurate Transcription of Admission Orders and Assessments
Penalty
Summary
The facility failed to accurately transcribe an admission order for one resident and ensure admission assessments were accurate for another resident. Resident #48 was admitted with diagnoses including Giant Cell Arteritis, COPD, and Asthma. The hospital discharge orders indicated Prednisone 8 mg daily, but the Medication Administration Record (MAR) showed Prednisone 80 mg was administered instead. This error was confirmed by the Director of Nursing and a Registered Nurse. The Medical Director stated that the resident had no negative side effects from the incorrect dosage, although the order was transcribed incorrectly. Resident #364 was admitted with diagnoses including Malignant Neoplasm of the Left Breast, Hypertension, and Osteoporosis. The Oral Cavity Observation and Clinical Admission assessments inaccurately documented the resident as edentulous with dentures, while the resident actually had natural teeth and a broken tooth. This discrepancy was confirmed through interviews with the resident, her daughter, a CNA, an LPN, and the MDS Coordinator. The assessments did not reflect the resident's actual dental condition, leading to inaccurate medical records.
Failure to Ensure Hospice Plan of Care in Medical Record
Penalty
Summary
The facility failed to ensure a coordinated plan of care with the hospice provider was available in the medical record for Resident #60. The facility's hospice contract and policy required that the hospice plan of care be included in the resident's medical record. However, upon review, it was found that Resident #60, who was admitted to hospice services on 2/2/2024, did not have the hospice plan of care documented in their medical record. This deficiency was confirmed through multiple interviews with facility staff, including Licensed Practical Nurses and a Registered Nurse, who were unable to locate the hospice plan of care in either the physical chart or the electronic medical record. Resident #60 had a complex medical history, including Hemiplegia and Hemiparesis following a cerebral infarction, complete traumatic amputation at the level between the left hip and knee, asthma, diabetes mellitus, atrial fibrillation, hypertension, and post-traumatic stress disorder. Despite the resident's significant medical needs and the requirement for coordinated care, the hospice plan of care was not available for facility staff to reference. The Director of Nursing confirmed that it was her expectation for the hospice plan of care to be accessible in the resident's medical record, but acknowledged that it was not available in this case.
Failure to Assist Residents with Hand Hygiene Before Meals
Penalty
Summary
The facility failed to assist four residents with hand hygiene before meals on one of the five hallways observed for meal service. The facility's policy, dated 6/1/2023, required that hands be clean before serving meals. However, during observations on 3/3/2024, staff did not offer or assist Residents #20, #75, #614, and #39 with hand hygiene before serving their lunch meals. Resident #20 had moderate cognitive impairment, Resident #75 and Resident #614 were cognitively intact, and Resident #39 had moderate cognitive impairment. Despite these varying cognitive statuses, none of the residents were assisted with hand hygiene before their meals. During the meal tray distribution on the 200 hallway, the Social Services Assistant, Director of Social Services, and a CNA were observed distributing meal trays without offering or assisting residents with hand hygiene. Interviews with the Social Services Assistant and the Director of Social Services confirmed that they did not offer or assist residents with hand hygiene prior to the meal. The CNA stated she was unaware that hand hygiene was required before meal service but acknowledged the requirement after being informed. The Director of Nursing stated that it was her expectation for residents to be offered or assisted with hand hygiene prior to meals.
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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