Humphreys County Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Waverly, Tennessee.
- Location
- 104 Fort Hill Road, Waverly, Tennessee 37185
- CMS Provider Number
- 445489
- Inspections on file
- 16
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Humphreys County Care And Rehabilitation during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and complex medical conditions experienced significant weight loss, but recommended nutritional interventions from the RD were not communicated to or implemented by clinical staff. The DON and NP were unaware of the recommendations, and the facility failed to ensure timely follow-up, resulting in actual harm due to unmet nutritional needs.
The facility did not maintain an adequate emergency water supply as required by its policy, with only a 3-day supply of bottled water for drinking and cooking and two out of four hot water heaters not operational. The Administrator confirmed there was not enough water to meet the needs of all residents and staff for a 3-day emergency period.
The facility did not maintain a qualified Dietary Manager as required, leaving the kitchen without appropriate supervision after the previous DM resigned. Staff interviews revealed confusion about who was in charge, with a CNA and a cook temporarily filling supervisory roles despite lacking the necessary credentials. The Registered Dietician only visited twice monthly and was not managing the kitchen, resulting in noncompliance with staffing regulations.
Staff failed to maintain resident dignity during dining by addressing a resident with inappropriate endearments and serving meals in the hallway to three residents without care-planned preferences. The affected residents had significant cognitive impairments and required assistance, and staff interviews confirmed these actions were not in line with facility policy.
The facility did not provide written information on how to formulate an advance directive to several residents, as required by policy. Medical record reviews and staff interviews confirmed that neither residents nor their responsible parties received the necessary documentation, affecting individuals with a range of cognitive and medical conditions.
A resident with moderate cognitive impairment reported missing money from her nightstand on multiple occasions, but the allegation was not reported to State or local agencies as required by facility policy. Staff confusion and lack of communication led to the failure to follow mandated reporting procedures for suspected misappropriation of resident property.
A resident with moderate cognitive impairment reported missing money from her nightstand. The facility's investigation was limited to interviews with the resident and her responsible party, and an observation of money in the room, but did not include staff interviews or comprehensive documentation, resulting in a failure to thoroughly investigate the misappropriation allegation.
Two residents did not have comprehensive care plans reflecting their current needs and physician orders. One resident with severe cognitive impairment and multiple psychotropic and opioid medications lacked care plan documentation for medication use and monitoring. Another resident with hemiplegia and contractures did not have care plan interventions for passive range of motion or hand splint application, despite physician orders requiring these treatments.
The facility did not timely update care plans for two residents after significant changes in their conditions or treatments. One resident's care plan was not revised promptly after a fall, and another resident's care plan was not updated to reflect discontinued diuretic and psychotropic medications, despite these changes being known to staff.
Unsecured disposable razors and cleaning chemicals were found in the rooms of several residents, including those with cognitive impairment and physical dependency. Despite facility policies requiring immediate disposal of sharps and removal of hazardous items, these items were left unattended on bathroom sinks. RNs and the DON confirmed that such items should not be left unsecured.
Medications were found unsecured in the bathrooms of two residents who required staff assistance, and a medication cart was left unlocked and unattended during administration. Additionally, temperature logs for medication refrigerators on two halls were incomplete, with multiple dates missing required entries. The DON confirmed these practices did not follow facility policy.
Staff failed to perform hand hygiene between assisting multiple residents during meal service, including handling food and straws with bare hands, and did not properly store soiled linens, leaving them on the floor in a resident's room. These actions were not in accordance with facility infection control policies, as confirmed by staff and the DON.
The facility failed to protect food from contamination due to improper hand hygiene and handling by staff, including CNAs and the Admissions Coordinator. Observations showed staff touching food with bare hands and not performing hand hygiene. Additionally, ice machines were found with stains and biofilm, indicating poor maintenance. An opened, undated ice cream container was also found in the resident refrigerator, lacking proper labeling.
The facility did not provide a private space for the Resident Council Meeting, which was held in an open and noisy Activity Room. The meeting was interrupted multiple times by staff and visitors, and the DON and Activities Director were unaware of the need for privacy, leading to a failure in honoring residents' rights to organize without interference.
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in care planning. One resident was not care planned for monitoring the effects of medications, while another was not care planned for the management of an indwelling catheter. These omissions were confirmed by the MDS Coordinator during interviews.
A facility failed to update a care plan for a resident after an unwitnessed fall. Despite a policy requiring care plan revisions following status changes, the resident's care plan was not updated with appropriate interventions after the incident. The resident, who was at risk for falls and required substantial assistance with ADLs, did not have their care plan revised post-fall, as confirmed by the ADON.
A resident with cognitive impairment was found accessing potentially hazardous items at a nursing station, including scissors and aerosol sprays. Staff interviews revealed that the resident was kept at the nursing station to prevent falls, but inadequate supervision and improper storage of chemicals led to the exposure. The DON and RN confirmed that such items should not be stored unattended.
Two residents in an LTC facility received improper indwelling urinary catheter care. A CNA left one resident uncovered and used the same washcloth for cleaning both the scrotum and catheter. Another CNA failed to perform hand hygiene between glove changes and did not clean the shaft of the penis during catheter care. The DON confirmed these actions were against facility policy.
A facility failed to maintain consistent communication with a dialysis center for a resident requiring dialysis, as evidenced by incomplete or missing communication forms. The facility's policy requires collaboration with the dialysis center to meet the resident's needs, but interviews revealed lapses in documentation and communication. The ADON acknowledged the need for accurate monitoring of forms, while the RN Charge Nurse noted inconsistent receipt of forms from the facility.
A resident with severe cognitive impairment and hypertension was administered Metoprolol and Amlodipine despite having a diastolic blood pressure below the physician's specified threshold. The facility's policy requires holding medications if vital signs fall outside prescribed parameters, but this was not followed, leading to a significant medication error.
Two residents with cognitive impairments were found with unsecured medications in their rooms and at the nursing station. A resident had mentholated ointment in her room despite being assessed as unable to self-administer medications. Another resident accessed a drawer with ointments at the nursing station, which should not have been unattended. The DON confirmed these storage lapses.
The facility failed to implement enhanced barrier precautions for residents with wounds and indwelling medical devices, as required by their policy. Observations showed that staff did not use PPE during care activities for residents with pressure ulcers, urinary catheters, and gastrostomy tubes. Interviews revealed a lack of awareness and implementation of these precautions, despite initial education and plans to implement them.
Failure to Implement Dietician Recommendations for Residents with Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for two residents who experienced significant weight loss. Policy review showed that the facility was required to monitor weight changes and implement, monitor, and modify interventions as needed. For both residents, the Registered Dietician identified significant weight loss and recommended the addition of house supplements twice daily. However, these recommendations were not communicated to or implemented by the appropriate clinical staff. The Nurse Practitioner confirmed she was not made aware of the recommendations, and the DON acknowledged that the process for reviewing and acting on dietary recommendations was not followed due to staff absence and lack of follow-up. Both residents involved had complex medical histories, including severe cognitive impairment, dementia, and conditions such as aphasia, Parkinson's Disease, and adult failure to thrive. Despite documented weight loss—nearly 10% for one resident and over 5% for the other—there was no evidence that the recommended nutritional interventions were ordered or provided. The failure to implement these interventions resulted in actual harm to the residents, as the facility did not ensure their nutritional needs were met according to policy and clinical assessment.
Insufficient Emergency Water Supply Maintained
Penalty
Summary
The facility failed to ensure a sufficient emergency water supply was available for all 76 residents, as required by its own policy. The policy specified the amount of water needed for drinking, handwashing, cooking, toilet flushing, and miscellaneous uses, based on the number of residents and staff. During observation and interviews, it was found that only a 3-day supply of bottled water for drinking and cooking was maintained by the Dietary Manager. Additionally, in the boiler room, two out of four hot water heaters, each with a capacity of 116 gallons, were not operational, with one having its front panel missing and both turned off. The Business Office Manager confirmed the limited operational capacity, and the Administrator acknowledged that the facility did not have enough water to maintain a 3-day emergency supply for the average number of 52 employees and all residents.
Failure to Maintain Qualified Dietary Management Staff
Penalty
Summary
The facility failed to employ sufficient and qualified dietary staff to manage the food and nutrition service for all 76 residents. The job description for the Director of Food Services requires a graduate of an accredited dietetic program, at least five years of supervisory experience in a medical facility, and registration as a Food Service Director in the state. However, interviews and observations revealed that the facility did not have a Dietary Manager (DM) at the time of the survey, as the previous DM had quit approximately two weeks prior. Staff interviews indicated confusion and lack of clarity regarding who was supervising the kitchen, with a Certified Nursing Assistant (CNA) temporarily called in to fill the DM role, but also being assigned to CNA duties on the resident care floor. Further interviews with dietary staff, the Registered Dietician (RD), and the Administrator confirmed that the kitchen was being supervised by a cook, who did not hold the required qualifications for the DM position. The RD only visited the facility twice a month and was not managing the kitchen. The Administrator acknowledged that there was no current DM, and the cook was acting as the supervisor. This lack of qualified dietary management resulted in the facility not meeting regulatory requirements for food and nutrition service staffing.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to maintain resident dignity and respect during dining, as evidenced by staff not using courtesy titles and serving meals in the hallway without care planning for such preferences. Specifically, a registered nurse addressed a moderately cognitively impaired resident using terms such as "honey," "baby," and "babydoll" during meal service, contrary to facility policy which requires the use of courtesy titles and prohibits the use of endearments. Additionally, certified nursing assistants served meals to three severely cognitively impaired residents in the hallway while they were seated in Geri-chairs or Broda chairs, despite none of these residents having care plans indicating a preference for hallway dining. Medical record reviews confirmed that the affected residents had significant cognitive impairments and required staff assistance for activities of daily living, including eating. Observations documented that meals were provided and assistance was given in the hallway rather than in designated dining areas or according to resident preference. Interviews with facility staff, including the RN, MDS Coordinator, and DON, confirmed that serving meals in the hallway without care planning and failing to use appropriate forms of address were not in accordance with facility policy or resident rights.
Failure to Provide Written Information on Advance Directives
Penalty
Summary
The facility failed to provide written information on how to formulate an advance directive to 9 out of 24 sampled residents. Policy review indicated that the Admissions Director or designee is responsible for providing this information prior to or upon admission. However, medical record reviews for multiple residents with various diagnoses, including chronic illnesses and cognitive impairments, showed no documentation that either the residents or their responsible parties received the required written information regarding advance directives. Interviews with facility staff confirmed the deficiency. The Administrator acknowledged the facility's responsibility to provide written documentation on advance directives, and the Social Services Director stated that there was no current process in place to ensure residents received this information. The lack of documentation and process affected residents with a range of cognitive abilities, from cognitively intact to severely impaired, and included those with significant medical conditions such as COPD, heart failure, diabetes, and cancer.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that allegations of misappropriation of resident property were reported in accordance with its own policy and regulatory requirements. Specifically, a resident with moderate cognitive impairment reported missing money from the top drawer of her nightstand, both in her current and previous rooms. The resident was unable to specify the exact amount or date the money went missing, but stated it was mostly loose one-dollar bills. The allegation was brought to the attention of the Administrator, who was also the Abuse Coordinator, but there was confusion among staff regarding who was handling the report, and the Social Services Director was not aware of the specific allegation. Despite the facility's policy requiring immediate reporting of any misappropriation of resident property to the State Regulatory Agency within 24 hours, the allegation was not reported to State and local agencies. Interviews with the resident's nephew confirmed that the resident had reported missing money on multiple occasions, but he had not informed staff. The Administrator and Social Services Director demonstrated a lack of communication and follow-through, resulting in the failure to report the incident as required.
Failure to Conduct Thorough Investigation of Misappropriation Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of misappropriation of property involving a resident who reported missing money from the top drawer of her nightstand. The resident, who was moderately cognitively impaired with a BIMS score of 11 and had diagnoses including Ulcerative Colitis, Atrial Fibrillation, and Urinary Tract Infection, was unable to specify the exact amount or date the money went missing. The allegation was reported to the Administrator, and a grievance form was completed noting the missing money, with the resident's nephew estimating the amount at no more than $6.00 over the past month. The facility's investigation included an interview with the resident, a telephone interview with the responsible party, and an observation of $6.00 hidden in a tissue box on the resident's nightstand. However, the investigation did not include interviews with staff or other residents who might have had knowledge of the incident, nor did it provide thorough documentation of all investigative steps or a comprehensive investigation summary. The Administrator confirmed that a thorough investigation should have included these elements to determine the root cause and resolution of the allegation.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by its own policy. For one resident with severe dementia, depression, and anxiety, the care plan did not address the use of multiple psychotropic and opioid medications, despite medical records showing active orders for antipsychotic, antidepressant, antianxiety, anticonvulsant, and opioid drugs. The resident's care plan lacked documentation on monitoring for side effects or interventions related to these medications, even though specific monitoring instructions were present in the physician's orders. The MDS Coordinator confirmed that the care plan should have included these elements. For another resident with hemiplegia, contractures, and joint derangement, the care plan did not include interventions for passive range of motion (PROM) or the application of hand splints, despite physician orders specifying their use for contracture management. The resident's medical record indicated limited range of motion and the need for both left and right hand splints, but these interventions were not reflected in the care plan. The MDS Coordinator acknowledged that the care plan should have addressed the current use of hand splints and PROM.
Failure to Timely Update Care Plans After Significant Changes
Penalty
Summary
The facility failed to update or revise care plans for two residents following significant changes in their conditions or treatments. For one resident with a history of bipolar disorder, lower back pain, and vertebral fractures, the care plan was not updated in a timely manner after a fall incident. The fall occurred on 8/8/2025, but the care plan was not revised to include new interventions until 9/3/2025. The MDS Coordinator confirmed that interventions should have been added the next working day, but this did not occur. For another resident with anxiety, delusions, depression, and dementia, the care plan continued to include interventions related to diuretic and psychotropic medications even after these medications had been discontinued as of 7/16/2025. The care plan was not revised to reflect this significant change in the resident's medication regimen. The MDS Coordinator confirmed that the care plan should have been updated to reflect the discontinuation of these medications.
Unsecured Sharps and Chemicals Found in Resident Rooms
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by allowing unsecured sharps and cleaning chemicals to be present in the rooms of five sampled residents. Policy review indicated that contaminated sharps should be immediately discarded into designated containers, and items posing risks to residents' health and safety should be confiscated if found in plain view. Despite these policies, observations revealed that disposable razors and cleaning chemicals were left unsecured in resident bathrooms. Registered nurses confirmed during interviews that these items should not have been left unattended or unsecured in resident rooms. The residents involved had varying degrees of cognitive impairment and physical dependency, including diagnoses such as dementia, depression, hypertension, heart failure, and respiratory conditions. Some residents required moderate to total assistance with activities of daily living. The unsecured items included disposable razors, aerosol air freshener, disinfectant spray, and surface cleaner, all found on or under bathroom sinks. The Director of Nursing confirmed that these items should not have been left unsecure and unattended in residents' rooms.
Medication Storage and Security Deficiencies
Penalty
Summary
Facility staff failed to ensure proper storage and security of medications in several instances. Medications were found unsecured in the bathrooms of two residents, both of whom were cognitively intact but required staff assistance for activities of daily living. The medications observed included nasal spray, eye drops, cough syrup, ointment, antifungal cream, and zinc oxide cream. Additionally, a medication cart on one hall was left unlocked and unattended during medication administration. Further deficiencies were identified in the monitoring of medication refrigerator temperatures. Temperature logs for medication refrigerators on two separate halls were found to have multiple dates with missing entries, indicating that daily temperature checks were not consistently performed as required by facility policy. The Director of Nursing confirmed that these practices did not comply with facility protocols for medication security and storage.
Failure to Maintain Infection Control During Dining and Linen Handling
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as evidenced by staff not performing hand hygiene during meal service and improper storage of soiled linens. Specifically, a Certified Nursing Assistant (CNA) was observed assisting multiple residents with meal tray setup, including handling food items and straws with bare hands, and did not perform hand hygiene between resident interactions or before handling additional meal trays. These actions were observed during several consecutive resident meal setups, contrary to the facility's hand hygiene policy, which requires staff to clean their hands between resident contacts and after handling potentially contaminated items. Additionally, soiled linens and clothing were observed left on the floor in a resident's room at multiple times throughout the day. The resident involved had severe cognitive impairment and required assistance with activities of daily living. Facility policy states that soiled linens should be collected at the point of use and placed in a designated receptacle, and should not be left on the floor or in the resident's room. Staff interviews confirmed that these practices were not followed, and the Director of Nursing acknowledged that both hand hygiene and proper linen handling procedures were not maintained.
Deficiencies in Food Handling and Equipment Cleanliness
Penalty
Summary
The facility failed to ensure food was protected from contamination due to improper hand hygiene and handling practices by staff members. Observations revealed that a Certified Nursing Assistant (CNA) and the Admissions Coordinator touched food with their bare hands, and multiple staff members failed to perform hand hygiene before serving food or after touching potentially contaminated surfaces. Specifically, CNA C handled a dinner roll with bare hands and failed to sanitize her hands after picking up a roll from the floor. Similarly, CNA D did not perform hand hygiene before donning gloves to assist a resident with a meal, and CNA B placed a dirty meal tray back on a cart with clean trays. The facility also failed to maintain cleanliness in its ice machines, which were found to have white stains, dark discoloration, and biofilm or pink slime, indicating a lack of proper cleaning and maintenance. The ice machines, used by all halls, had visible build-up and discoloration, which the Administrator confirmed should not be present. The Maintenance Director admitted to not being sure about the cleaning frequency and confirmed that this was the first time he had deep cleaned the ice machine since taking the position. Additionally, the facility did not adhere to its policy on food storage, as evidenced by an observation of an opened, undated gallon of ice cream in the resident refrigerator, lacking a name or room number. The Dietary Manager confirmed that the ice cream should have been labeled with a name and date. These deficiencies highlight lapses in the facility's adherence to its own policies regarding hand hygiene, food handling, and storage, as well as equipment cleanliness.
Lack of Privacy for Resident Council Meeting
Penalty
Summary
The facility failed to provide a private space for the Resident Council Meeting, which compromised the residents' right to organize and participate in resident groups without interference. The meeting was held in the Activity Room, which had large openings on each side, making it accessible to anyone in the vicinity, including the 100 Hall, Administrators Offices, and Dining Room. No signs were posted to indicate that a meeting was in progress, and the environment was noisy, necessitating the use of a microphone to amplify the speaker's voice. During the meeting, several interruptions occurred, including the entry of the Assistant Director of Nursing, a housekeeper collecting trash, a visitor speaking to a resident, and a social worker standing in the doorway. Interviews with the Director of Nursing and the Activities Director revealed a lack of awareness regarding the need for a private setting for these meetings, with the Activities Director acknowledging that the meetings were typically held in the Activity Room and expressing an intention to find a more private location in the future.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in care planning. Resident #33, who was admitted with multiple diagnoses including diabetes, atrial fibrillation, and depression, was not care planned for monitoring the effects of anticoagulants, antibiotics, and diuretics. Despite having a BIMS score indicating cognitive intactness, the resident's care plan did not include necessary monitoring for bleeding, dehydration, and infection risks, as confirmed by the MDS Coordinator during an interview. Similarly, Resident #46, admitted with conditions such as peripheral vascular disease and chronic kidney disease, was not care planned for the management of an indwelling catheter. The resident, who had a BIMS score indicating moderate cognitive impairment, was observed with an indwelling urinary catheter in place, yet the care plan did not address this aspect of care. The MDS Coordinator acknowledged the absence of a care plan for the indwelling catheter during an interview, confirming the deficiency in care planning for this resident.
Failure to Update Care Plan Post-Fall
Penalty
Summary
The facility failed to update and revise the care plan for a resident who was reviewed for falls. The facility's policy, dated 3/5/2024, mandates that care plans be reviewed and revised when a resident experiences a status change. Resident #29, who was admitted with diagnoses of muscle weakness, ataxic gait, and psychotic disorder, had a BIMS score indicating cognitive intactness and required substantial staff assistance with most ADLs. The care plan dated 12/22/2020 identified the resident as at risk for falls, with an intervention for a medical doctor to evaluate on 1/22/2024. However, after an unwitnessed fall on 1/22/2024, the care plan was not updated with appropriate interventions. The Assistant Director of Nursing confirmed that an intervention should have been added post-fall.
Resident Exposed to Accident Hazards Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that a resident was free from accident hazards, as evidenced by the presence of potentially dangerous items accessible to a cognitively impaired resident. Resident #65, who was admitted with multiple diagnoses including dementia and anxiety disorder, was observed at the nursing station going through drawers that contained items such as toothpaste, blunt point scissors, Clorox aerosol spray, and Sani Wipes. The resident had a Brief Interview for Mental Status (BIMS) score of 4, indicating cognitive impairment, which increased the risk of harm from accessing these items. Interviews with facility staff revealed a lack of proper supervision and storage of hazardous materials. A Certified Nursing Assistant (CNA) acknowledged that the resident should not have been going through the drawers, and the Director of Nursing (DON) and a Registered Nurse (RN) both confirmed that chemicals should not be stored unattended at the nursing station. The staff explained that the resident was kept at the nursing station to prevent falls, as she had a history of wandering and falling when left in her room. However, this measure inadvertently exposed her to accident hazards due to inadequate supervision and improper storage of potentially dangerous items.
Deficient Catheter Care Practices in LTC Facility
Penalty
Summary
The facility failed to provide appropriate indwelling urinary catheter care for two residents, leading to deficiencies in care. For Resident #45, who was severely cognitively impaired and dependent on staff for all activities of daily living, a CNA was observed performing catheter care improperly. The CNA left the resident uncovered while gathering supplies, cleaned the scrotum and catheter with the same washcloth, and failed to use a different part of the washcloth during the process, which is against the facility's policy. For Resident #56, who was also severely cognitively impaired and had an indwelling urinary catheter, a CNA failed to clean the over bed table or place a barrier before starting catheter care. The CNA did not perform hand hygiene after removing gloves and before donning a new pair, and failed to clean the shaft of the penis during the procedure. The Director of Nursing confirmed that these actions were not in compliance with the facility's policy, which requires proper hand hygiene and specific cleaning techniques during catheter care.
Failure in Dialysis Care Coordination
Penalty
Summary
The facility failed to ensure ongoing communication and coordination of care with the dialysis center for a resident requiring dialysis services. The facility's policy on hemodialysis, dated June 3, 2024, mandates collaboration with the dialysis facility to meet the resident's needs and ensure safe administration of dialysis treatment. However, the facility did not maintain consistent communication with the dialysis center, as evidenced by incomplete or missing dialysis communication forms for Resident #64. The forms lacked post-dialysis vital signs, weight, medication administered, and fluid intake information for several dates in May and June 2024. Interviews with the Assistant Director of Nursing (ADON) and the RN Charge Nurse at the dialysis clinic revealed lapses in communication and documentation. The ADON acknowledged that the facility should have copies of the dialysis communication forms for each visit and that the charge nurse should monitor these forms for accuracy. The RN Charge Nurse at the dialysis clinic reported inconsistent receipt of communication forms from the facility and noted that other nursing homes routinely send forms with their residents. The RN Charge Nurse also highlighted the absence of documentation regarding communication with the facility about the resident's condition or any issues during treatment.
Significant Medication Error Due to Non-Adherence to Physician Orders
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the administration of antihypertensive medications despite contraindicated blood pressure readings. The facility's policy requires that medications be administered by licensed nurses or authorized staff according to physician orders and professional standards, including holding medications if vital signs fall outside prescribed parameters. However, the medical records revealed that a resident with severe cognitive impairment and a history of hypertension was given Metoprolol Tartrate and Amlodipine Besylate on two consecutive days, despite having a diastolic blood pressure reading below the physician's specified threshold of 60. The resident's medical records indicated a systolic blood pressure of 101 and a diastolic blood pressure of 55 on one of the days, with no blood pressure recorded on the following day. The Assistant Director of Nursing confirmed that the medications should have been withheld due to the low diastolic blood pressure. This oversight in medication administration represents a significant medication error, as the facility did not adhere to the physician's orders to hold the medications under these circumstances.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored appropriately, as evidenced by unsecured and unattended medications found in the rooms of two residents. Resident #3, who was admitted with diagnoses including Dementia and severe cognitive impairment, was observed with a bottle of mentholated ointment on her over-bed table. The facility's policy allows for self-administration of medication only after an interdisciplinary team assessment, which had determined that Resident #3 was not capable of safely self-administering or storing medications. Despite this, the mentholated ointment was found in her room on multiple occasions, and the Director of Nursing confirmed that it should not have been there. Similarly, Resident #65, who also had a diagnosis of Dementia and cognitive impairment, was observed accessing a drawer at the nursing station containing 26 packages of vitamin A & D ointment and a tube of phytoplex. The Certified Nursing Assistant confirmed that the resident should not have been going through the drawers containing chemicals. The Director of Nursing acknowledged that medications should not be stored unattended in the nursing station drawers, indicating a lapse in the facility's medication storage protocols.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain infection prevention practices for five of seven sampled residents who required enhanced barrier precautions. The facility's policy, dated June 18, 2024, mandates the use of enhanced barrier precautions for residents with wounds or indwelling medical devices to prevent the transmission of multidrug-resistant organisms. However, observations revealed that staff did not adhere to these precautions, as evidenced by the lack of personal protective equipment (PPE) usage during care activities for residents with pressure ulcers, indwelling urinary catheters, and gastrostomy tubes. Resident #9, with a diagnosis of a stage 4 pressure ulcer, did not have PPE available for enhanced barrier precautions during wound care performed by an LPN, who was unaware of the requirement. Similarly, Resident #39, who had an indwelling urinary catheter, was observed receiving a shower from an occupational therapist assistant without PPE usage. Resident #45, also with an indwelling urinary catheter, received catheter care from a CNA without PPE, and Resident #56, with a similar condition, was observed in the same situation. Additionally, Resident #319, who required enteral nutrition via a gastrostomy tube, had medications administered by an RN without PPE. Interviews with staff, including the Director of Nursing and Assistant Director of Nursing, revealed a lack of awareness and implementation of enhanced barrier precautions. The Assistant Director of Nursing acknowledged that enhanced barrier precautions were an addition to standard precautions and were recommended for residents with wounds, catheters, and indwelling medical devices. However, the facility had not yet implemented these precautions, despite initial education in April and plans to implement them in June. The Director of Nursing confirmed that no residents were on enhanced barrier precautions at the time of the survey.
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Surveyors found that staff did not follow the facility’s infection prevention policies, including Enhanced Barrier Precautions (EBP), hand hygiene, and urinary catheter management. A respiratory therapist performed trach care and suctioning for two residents with tracheostomies without donning required gowns or masks, placed supplies and an inner cannula on the resident’s abdomen and linens, and left a room wearing contaminated gloves. An RN administered meds via a feeding tube for a resident with a gastrostomy, then performed eyelid scrubs without changing gloves or performing hand hygiene between routes of care and without using a gown despite EBP signage. CNAs delivered and set up lunch trays for three residents who required at least some assistance with hygiene or meals but did not offer hand hygiene before eating, contrary to policy. In addition, a resident with a urinary catheter was observed in bed with the drainage bag lying on the floor, rather than suspended from the bed as confirmed by nursing staff and the IP.
Administration allowed an unqualified individual to be hired and work as an LPN by failing to verify licensure and reconcile name discrepancies across hiring documents. The individual’s I-9, birth certificate, and out-of-state driver’s license reflected one last name, while the TN LPN license verification on file belonged to a different nurse with the same first name but a different last name. Abuse registry checks were completed under both names, but no national background check or documentation explaining the differing names was present. The person was offered a temporary/contract LPN position, worked multiple shifts, and had conflicting separation notices, with no documentation of a formal rehire. The HR Director confirmed there was no hiring policy and that the individual worked onsite as an LPN before being terminated for failure to attend or complete training.
Administration failed to ensure nursing services were provided by qualified personnel when an unlicensed individual was hired and allowed to work as an RN and Unit Manager using another nurse’s license. Pre-employment documents for this staff member contained inconsistent SSNs and birth dates across the application, background check, W-4, and I-9, and the background report noted the SSN could not be validated. No abuse registry check or RN license verification was completed before hire, and a later license verification showed the last name on the RN license did not match the individual’s last name. The imposter, a walk-in applicant without a resume, worked multiple shifts providing nursing services before being separated as a voluntary termination, and facility staff did not question the documented discrepancies.
Administration allowed an unlicensed individual to be hired twice and function as an LPN using another LPN’s Tennessee license. During the first hire, conflicting SSNs appeared on the application and tax forms, the I‑9 identified the imposter by her own name and out‑of‑state driver’s license, and the license verification was for a different nurse with only the same first name; no Tennessee Abuse Registry check was documented, and the imposter worked multiple shifts before resigning. During the second hire, a different SSN was used, no I‑9 or supporting identity documents were on file, and the same other nurse’s license was again used for verification; the imposter worked several days before resigning. The Administrator reported that the same resume was used for both hires and that the facility had no formal hiring policy, only a checklist.
Administration failed to ensure nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s license. The facility’s own employment policy requiring HR completion of I-9 Section 2, consistent SSN use, and verification of license and abuse registry status was not followed. The imposter’s application and background check contained conflicting SSNs, names, and birthdates, and the I-9 was not signed by HR. An abuse registry check was run only on one SSN, and discrepancies were not investigated. Time records showed the imposter worked several shifts and had patient access, while leadership later confirmed she remained on the books until being treated as a voluntary termination for not picking up shifts.
Administration failed to ensure nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN under another nurse’s license. Facility records showed multiple unexplained discrepancies in the individual’s name, SSN, and birthdate across the background check, I-9, W-4, Consumer Information Sheet, and separation notice, and the I-9 was never completed or signed by facility staff. Time records confirmed the imposter worked several shifts as an RN before being terminated for no call/no show, and an abuse registry check was not completed until long after termination. The facility did not produce hiring policies or documentation that anyone questioned the conflicting identification information before or during this person’s employment.
Staff failed to honor a resident’s right to refuse care when CNAs proceeded with a scheduled shower despite the resident verbally declining. The resident, who had severe dementia with agitation and was dependent on staff for bathing, had a care plan directing staff to discuss objections, inform of risks, offer choices, and accept refusals. Instead, after the resident said they did not want a shower, one CNA pulled off the covers, and the CNAs placed the resident in a shower chair and continued with the shower because it was the resident’s assigned shower day, contrary to facility policy and the care plan.
A resident with severe cognitive impairment and multiple comorbidities was admitted for rehab and had clearly documented full code status in the face sheet, care plan, and physician orders. During the night, the resident was last observed awake and later found unresponsive with no heart sounds, pulse, or respirations. Staff initiated CPR and continued until the resident was pronounced deceased, but the record contained no evidence that EMS/911 was contacted or that an AED was obtained or used, despite facility policy and leadership expectations that full code residents receive CPR with 911 activation and AED use, and despite the presence of two AEDs in the facility.
A resident with severe cognitive impairment, type 2 DM, CKD, and a history of falls had physician orders for blood glucose checks before meals and at bedtime and for sliding scale insulin aspart four times daily. Facility policy required verification of insulin orders, blood glucose monitoring per orders, and documentation of results and doses. However, after an NP attempted to edit the sliding scale order in the EHR, the order remained unsigned and inactive in the queue, preventing it from appearing on the MAR. Nursing staff did not identify that the insulin order was missing, resulting in multiple missed blood glucose checks and insulin doses over several days, despite the resident’s care plan directing staff to follow physician orders for diabetes management.
The facility failed to maintain a clean and sanitary environment in multiple resident rooms and bathrooms, despite policies requiring routine cleaning and disinfection. Observations over several days found a motorized wheelchair and another wheelchair with attached cushion soiled with dried, multi-colored debris. Several resident bathrooms had unclean conditions, including a trash can without a liner and with dried brown residue, toilets with dried yellow residue on the seats, and yellow/orange or brown substances around the bases of multiple toilets. During an on-site check, the Administrator confirmed that the residue around one toilet could be wiped away and that the area was not clean.
Failure to Follow EBP, Hand Hygiene, and Catheter Practices During Respiratory, Enteral, and Daily Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies, including Enhanced Barrier Precautions (EBP), hand hygiene, and urinary catheter management. The facility’s EBP policy required staff to perform hand hygiene, review EBP signage, and don gown and gloves prior to high-contact resident care activities such as tracheostomy care, suctioning, and device care, then remove PPE and perform hand hygiene before leaving the resident’s room. For Resident #1, who had epilepsy, acute on chronic respiratory failure, a tracheostomy, and ventilator dependence, a respiratory therapist entered the room where EBP signage was posted, used pocket hand sanitizer, and donned gloves but did not don a gown or mask. The therapist placed clean gauze and used split gauze directly on the resident’s abdomen, allowed the tracheostomy inner cannula to roll from the abdomen onto the linens, and then left the room carrying a box while still wearing the same contaminated gloves, only discarding them later at the respiratory therapy cart. The therapist acknowledged not setting up supplies appropriately, not discarding gloves and performing hand hygiene before leaving the room, and not following EBP, stating she believed EBP was only required for residents with an active infection. For Resident #8, who had traumatic brain injury, quadriplegia, acute respiratory failure, and a tracheostomy, the same respiratory therapist again entered a room with EBP signage and donned gloves but no gown or mask before performing tracheal suctioning using an in-line suction catheter. The resident had reflex coughing during suctioning. After completing suctioning, the therapist discarded gloves and used pocket hand sanitizer but again did not follow the full EBP requirements. The infection preventionist later confirmed that EBP was required for high-contact care such as tracheal care and suctioning, and that gloves should be discarded before leaving the room with hand hygiene performed each time gloves are removed. The facility also failed to follow EBP and hand hygiene practices during medication administration for Resident #22, who had chronic respiratory failure, quadriplegia, tracheostomy status, and gastrostomy status, and who had long- and short-term memory deficits with severely impaired decision-making. A registered nurse entered the resident’s room, where EBP signage was posted, donned gloves but not a gown, and administered medications via the gastrostomy tube using a piston syringe, flushing with water as ordered. With the same used gloves still on, the nurse rinsed the piston syringe in the room sink, set it on paper towels to dry, and then performed OcuSoft eyelid scrubs to both eyes without changing gloves or performing hand hygiene between the different routes of care. The nurse confirmed she did not don a gown and did not perform hand hygiene or change gloves between the feeding tube medication administration and the eye care, and the infection preventionist confirmed that EBP and hand hygiene with glove changes were expected between administering medications by different routes. Additional deficiencies were identified in hand hygiene assistance before meals and urinary catheter management. The facility’s resident handwashing policy required staff to offer hand hygiene before meals. Resident #47, who had acute and chronic respiratory failure, epilepsy, atrial fibrillation, and chronic pulmonary edema and was dependent for hygiene and feeding assistance, received a lunch tray from a CNA who set up the tray and left without offering hand hygiene assistance. Resident #31, with COPD, acute and chronic respiratory failure, morbid obesity, and a care plan indicating partial to moderate assistance with hygiene, also had a lunch tray delivered and set up by a CNA who exited without offering hand hygiene. Resident #66, with COPD, chronic respiratory failure, generalized muscle weakness, and substantial to maximal ADL needs including meal assistance, likewise had a lunch tray delivered and set up without being offered hand hygiene. One CNA acknowledged residents were to be offered hand hygiene before meals, and another stated she had not offered hand hygiene unless residents mentioned it. The infection preventionist confirmed staff were expected to offer hand hygiene assistance to all residents prior to meals. The facility further failed to maintain proper urinary catheter bag positioning for Resident #15, who had chronic osteomyelitis, depression, anxiety, paraplegia, and required assistance with ADLs, including urinary catheter care per orders and protocol. During observation, the resident was in bed with the urinary catheter drainage bag lying on the floor beside the bed. A licensed practical nurse confirmed the catheter bag should be hung from the bed, and the infection preventionist confirmed catheter bags were to be suspended off the ground to prevent infection. These observations demonstrated non-adherence to the facility’s infection prevention and control practices related to EBP, hand hygiene, and catheter management across multiple residents and care situations.
Imposter Hired and Employed as LPN Without Proper License Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an LPN using another nurse’s Tennessee license. Personnel file review showed that the individual, referred to as Imposter Nurse A, had an I-9 form completed with her legal first and last name, supported by a birth certificate and an out-of-state driver’s license, and a Tennessee Criminal History Record Request indicating no Tennessee criminal history under that name. However, the nursing license verification in the file was for a different person, an LPN with the same first name but a different last name (LPN C). Two Tennessee Abuse Registry checks were present, one under LPN C’s name and one under Imposter Nurse A’s name, but there was no documentation explaining or reconciling the name discrepancies between the I-9, the license verification, and other employment documents. There was also no national background check in the personnel file. The facility issued an offer letter to Imposter Nurse A for a temporary/contract LPN position, and time sheets showed she worked multiple shifts on several dates. Two separation notices documented voluntary separation without notice, with differing last days worked, and there was no paperwork provided to explain her apparent rehire after the first termination. During interview, the Human Resource Director acknowledged there was no hiring policy, confirmed that Imposter Nurse A worked onsite as an LPN, and stated she was terminated for failure to attend or complete training and for failure to come in as needed. No information was provided to surveyors showing any cross-check or investigation of the inconsistent names across the employment application, I-9 form, and nursing license verification, resulting in the facility employing an unqualified person in an LPN role.
Imposter RN Hired and Allowed to Function Without Proper Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s Tennessee license. Facility policy titled “Abuse Program Policy” required pre-employment screening, including obtaining a copy of the state license for licensed positions and completing a criminal background check per state statute. The application for employment for the imposter nurse contained a scratched-out Social Security Number (SSN) with a different SSN written above that did not match the SSN on the I-9 form, and the birth date on the application also did not match the I-9. The background screening report showed an SSN and birth date that did not match the I-9 and included a note stating “UNABLE TO VALIDATE SSN.” A W-4 form contained an SSN that did not match the background check. The I-9 form listed the imposter’s legal first and last name, with a Social Security card and valid Tennessee driver’s license, but the birth date on the I-9 differed from the birth date on the background check. Review of the personnel file revealed no evidence that an abuse registry check was completed prior to hire, and there was no evidence that a license verification was done before the imposter nurse’s start date. Time cards showed the imposter worked multiple days in February and March as a Unit Manager. A later QuickConfirm license verification showed that the last name on the validated RN license did not match the imposter’s last name. Interviews with the DON, HR representative, and Administrator confirmed that the imposter was a walk-in applicant who did not provide a resume, that in-house HR was responsible for ordering background checks with corporate as backup, and that the imposter worked in the facility as a Unit Manager and was only separated as a voluntary termination for inability to uphold weekend schedule obligations. There was no evidence that the facility questioned the discrepancies in names, birth dates, or SSNs on the pre-employment documents, resulting in the employment of an unqualified person to render nursing services as an RN.
Imposter Nurse Hired Twice and Allowed to Function as LPN Without Proper Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and allowed to function as an LPN on two separate occasions using another nurse’s Tennessee license. For the first hire, the personnel file showed an employment application dated 02/08/2023 with a Social Security Number (SSN) that did not match the SSN on the W‑4 form dated 02/13/2023. The I‑9 form dated 02/13/2023 listed the imposter’s legal first and last name, supported by a birth certificate and an out‑of‑state driver’s license, and the last name on the I‑9 matched the driver’s license. However, the license verification form in the file was for a different individual, an LPN with the same first name but a different last name, and there was no evidence that a Tennessee Abuse Registry check was completed prior to the 02/13/2023 hire date. Time punch records showed the imposter worked multiple shifts in February, March, April, and May 2023 before being terminated on 06/06/2023, with the termination form citing voluntary resignation due to chronic absenteeism and tardiness. For the second hire, the imposter was rehired with a personnel file showing that the SSN on the employment application, W‑4, and background check matched each other but differed from the two SSNs used during the first hire, meaning three different SSNs were used across the two employment periods. There was no I‑9 form or supporting identity documents in the file for the rehire. A license verification form again showed a nursing license in the name of the same LPN whose license had been used previously, with the same first name as the imposter but a different last name and a later expiration date. The background screening report dated 02/13/2024 used the SSN from the employee application, which did not match the SSN previously submitted on the I‑9 form from the first hire. Time punch data showed the imposter worked several days in May 2024 before a termination dated 06/24/2024, which documented voluntary resignation after failing to provide a schedule and not returning after orientation. In an interview, the Administrator stated the facility used the same resume for both hires and that the facility did not have a hiring policy, only a checklist.
Imposter RN Hired and Allowed to Work Without Proper License Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s Tennessee RN license. The facility’s Employment policy required the HR Director to complete Section 2 of the I-9, conduct background investigations, and verify licenses and abuse registry status using the applicant’s registration or Social Security number. Review of the imposter’s employment application showed a Social Security number scratched out and replaced with another number that did not match the SSN used on the background check. The background check listed both the imposter’s name and the legitimate RN’s name, and it showed the legitimate RN’s license number. The birthdate on the I-9 did not match the birthdate on the background check, and Section 2 of the I-9 was not signed by the HR Director as required by policy. Further review showed that an abuse registry search was completed using the SSN from the Social Security card submitted with the I-9, but no search was conducted using the SSN listed on the background check. The separation notice for the imposter listed her real first and last name with an SSN that again did not match the SSN on the background check, and documented employment from mid-June to late November with the reason for termination as voluntary due to not picking up shifts for over three months. Employee time entries showed the imposter worked multiple days in June and one day in July. The DON confirmed that the imposter used an online artificial intelligence website for charting and stated the imposter had access to patients for one day in July. The Administrator confirmed the imposter was considered employed during the stated period and was not formally fired or documented as having quit. There was no evidence that the facility questioned the discrepancies in names, birthdates, or Social Security numbers on the pre-employment documents, resulting in the employment of an unqualified person as an RN.
Imposter RN Hired and Allowed to Work Despite Multiple Identification Discrepancies
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s Tennessee license. Personnel file and document review showed multiple inconsistencies in the imposter nurse’s identifying information that were not questioned by the facility. The background check dated 06/14/2024 used a Social Security Number (SSN) that did not match the SSN on the Social Security card submitted. The I-9 form dated 06/15/2024 listed the imposter’s legal first and last name, with a copy of her Social Security card and a valid Tennessee driver’s license, but the SSN on the I-9 did not match the SSN on the Social Security card. The I-9 form was not completed, signed, or dated by any facility representative. Time punch data showed the imposter nurse worked multiple days in June and July 2024. A separation notice dated 07/31/2024 listed the imposter’s real first and last name with an SSN that did not match the SSN on the I-9 form, and documented employment dates from 06/12/2024 to 07/31/2024 with termination for no call/no show. An undated Consumer Information Sheet listed the imposter’s first and last name with the legitimate RN’s last name as her middle name, a birth year that did not match the I-9, and an SSN that did not match the SSN on the W-4 form or the separation notice. The abuse registry check for the imposter was not completed until 08/04/2025, after termination. The facility did not provide any hiring policies and there was no evidence that staff questioned the discrepancies in names, birth dates, or SSNs on the pre-employment forms, resulting in the employment of an unqualified person as an RN.
Failure to Honor Resident’s Refusal of Shower and Right to Self-Determination
Penalty
Summary
The deficiency involves staff failure to honor a resident’s right to self-determination and refusal of treatment, specifically related to bathing. Facility policy on Resident Rights and Responsibilities states that residents have the right to refuse treatment and to be informed of the medical consequences of such refusal, and to exercise their rights without discrimination or reprisal. Resident #31, admitted in late 2023, had severe dementia with agitation, a BIMS score of 3 indicating severe cognitive impairment, and was dependent on staff for showering and personal hygiene. The resident’s care plan identified behavior problems and resistance to care related to dementia, knowledge deficit, denial of illness and risk factors, and mental/emotional illness, with interventions directing staff to discuss objections and fears, inform the resident of risks of non-compliance, offer choices, and accept and respect the resident’s right to refuse care. Despite these policies and care plan interventions, staff proceeded with a shower after the resident refused. A CNA assigned to the resident reported that the resident had refused a shower, and another CNA responded that it was the resident’s shower day and that the shower should be provided. According to written statements, when the CNAs entered the room and informed the resident it was shower day, the resident stated, “No I don’t want a shower.” One CNA then told the resident they were getting a shower and pulled the covers off the resident. The CNAs placed the resident in a shower chair and continued with the shower despite the expressed refusal. During a later interview, the CNA confirmed instructing the other staff member to go ahead and provide the shower because it was the resident’s scheduled shower day, demonstrating that the resident’s right to refuse care and the care plan interventions to respect refusals were not followed.
Failure to Contact EMS and Use AED During CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its CPR and emergency response policy for a resident who was a documented full code. Facility policy required staff to call 911 for resident emergencies, obtain and use an AED, and initiate CPR for full code residents unless there was a POST form or other physician order to withhold CPR, or the resident showed American Heart Association (AHA) signs of clinical death. The 2020 AHA Adult Basic Life Support Algorithm directs healthcare providers to activate the emergency response system, obtain an AED, and use it as soon as available when a person has no breathing or only gasping and no pulse. The facility had two AEDs and staff were educated on AED use as part of CPR training. Resident #78 was admitted for rehabilitation and 24-hour skilled nursing care following a hospitalization due to a fall at home and had a medical history including atrial fibrillation with multiple cardioversions, dysphagia, chronic kidney disease, mild cognitive impairment with memory loss, hypertension, UTI, influenza, and type 2 diabetes mellitus. The resident’s profile, care plan, and physician’s orders all documented full code status. A 5-day MDS showed a BIMS score of 4, indicating severe cognitive impairment. On the evening prior to the event, an RN documented that the resident was sitting in a wheelchair watching television at 8:20 PM, was assisted to the bathroom at 10:00 PM, and was checked again at 12:00 AM. At approximately 2:00 AM, a CNA found the resident unresponsive and notified the RN, who assessed the resident and documented no heart sounds, pulse, or respirations. Staff initiated CPR and continued efforts until the RN pronounced the resident deceased at 2:45 AM. There was no documentation in the medical record that EMS/911 was contacted or that an AED was used during the resuscitation attempt, despite facility policy and the expectations stated by the DON, LPN, NP, and Medical Director that staff should call 911, obtain and use an AED, and continue CPR until EMS arrival for a full code resident. An email from the local fire department indicated there were no EMS reports for the resident on the date in question, and the DON stated she had no evidence to verify that EMS was contacted and no AED log to show whether an AED was used. The Administrator stated she expected staff to follow the CPR policy and properly document all care and services provided, but the record lacked evidence of EMS notification or AED utilization for this full code resident.
Failure to Activate and Follow Sliding Scale Insulin and Blood Glucose Orders
Penalty
Summary
The deficiency involves the facility’s failure to activate and carry out physician orders for blood glucose monitoring and sliding scale insulin for a resident with type 2 diabetes. Facility policy on insulin administration required verification that insulin type, dosage, strength, and method of administration corresponded with the physician’s order, checking blood glucose per physician order or facility protocol, and documenting blood glucose results and insulin doses. The resident’s care plan for diabetes directed staff to check blood sugar levels via fingerstick per physician orders and to administer medications per physician orders. The resident was admitted for rehabilitation and 24-hour skilled nursing care following a hospitalization due to a fall at home and had a medical history that included chronic kidney disease and type 2 diabetes mellitus. A 5-day MDS showed severe cognitive impairment with a BIMS score of 4 and an active diagnosis of type 2 diabetes, with insulin injections received. Physician orders directed staff to check the resident’s blood sugar before meals and at bedtime, four times a day, and to administer insulin aspart via a sliding scale four times a day. These orders were in place with a specified stop date and then renewed. Despite these orders, the medication record for the resident showed no documentation of blood sugar levels or administration of insulin aspart at multiple ordered times over several days. A family member reported concern that the resident’s blood sugar levels had not been checked for the past couple of days and that the resident was not on a short-acting insulin. A medication error report later identified that the NP had updated the sliding scale insulin order, but the update was not signed and remained in the unsigned order queue, leaving the insulin aspart order inactive on the MAR. As a result, nursing staff could not see the updated order and missed multiple doses of insulin aspart. The NP stated that she had intended to edit, not discontinue, the sliding scale order, but the electronic medical record required her to unsign the order to edit it, and she failed to reactivate it. The DON stated that nursing staff failed to identify that the insulin aspart order was missing and remained in the queue awaiting reactivation, and the Administrator stated that her expectation was for staff to follow company policy and for the DON or designee to verify that all active orders were visible for nurses when a plan of correction for missing insulin doses had been implemented. A physician statement documented that the resident had uncontrolled type 2 diabetes mellitus, CKD stage III, and hyperlipidemia, and that the resident received sliding scale insulin on one day but did not receive any sliding scale insulin on the following two days. The physician noted that the resident’s blood glucose reached a maximum level of 343 mg/dL during this period and that the sliding scale insulin order was later replaced and resumed. These findings collectively show that the facility did not provide treatment and care according to physician orders and the resident’s care plan for diabetes management, due to the failure to activate and monitor the sliding scale insulin and blood glucose orders in the electronic system and to recognize and correct the missing active order on the MAR.
Failure to Maintain Clean and Sanitary Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean and sanitary environment in multiple resident rooms and bathrooms, contrary to its own policies on routine bathroom cleaning and routine cleaning and disinfection. The facility’s policies, dated 6/2025, required providing a clean and sanitary environment, cleaning the entire toilet including the handle and underside of the flush rim with disinfectant and appropriate contact time, and reporting damaged items in need of repair. Observations conducted on several days showed that in one room, a motorized wheelchair had dried debris on the cushion, arms, and a large amount of multi-colored debris on the undercarriage. In another room, a wheelchair with a fabric heel protector cushion used as an armrest was spattered with small to pea-sized unknown multi-colored particles. Additional observations revealed that several resident bathrooms were not maintained in a sanitary condition. One bathroom had a trash can without a bag and with a dried brown substance on the outside, rim, and inside of the can, as well as a toilet seat with two areas of dried yellow residue and a yellow/orange substance around the base of the toilet. Other bathrooms in different rooms had yellow/orange or brown residue around or at the front base of the toilets. During an observation and interview in one of the bathrooms, the Administrator initially suggested the substance around the toilets might be related to the wax ring, but after wiping a small area with a wet wipe, the yellow/orange substance was easily removed, and the Administrator confirmed the area around the toilet was not clean.
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