Huntingdon Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntingdon, Tennessee.
- Location
- 635 High Street, Huntingdon, Tennessee 38344
- CMS Provider Number
- 445210
- Inspections on file
- 19
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Huntingdon Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a PEG tube and diagnoses including diabetes, seizures, dementia, and gastrostomy status had continuous Jevity 1.5 enteral feeding and water flushes ordered, but surveyors observed that the water flush solution and tube feeding were not replaced within 24 hours and were not properly labeled. On repeated observations over two days, a water bag was found infusing beyond 24 hours, and a Jevity feeding and a clear bag of water were found either dated from the prior day or lacking any date or time. The DON confirmed that tube feedings and water should not hang for more than 24 hours and should be labeled and dated, but this was not done.
Two residents received oxygen therapy without proper adherence to physician orders and facility policy. One resident with chronic respiratory and cardiac conditions had an order for continuous O2 at 2 L/min via nasal cannula, but surveyors observed the concentrator set higher and found no orders or documentation for routine tubing/cannula changes despite ongoing use. Another resident with dementia and cardiac comorbidities was repeatedly documented as receiving O2 via nasal cannula over several months, yet there was no corresponding physician order or care plan entry during that period, and later observations showed the concentrator set above the stated ordered rate. Staff interviews confirmed that oxygen should not be given without an order and should be administered at the prescribed rate with appropriate tubing/cannula change orders.
Two cognitively impaired residents, both lacking capacity to consent, were found engaged in sexual activity after one exhibited ongoing hypersexual behaviors that were not adequately monitored or managed by staff. Despite staff observations and reports of inappropriate behaviors, there was a delay in medication administration and no consistent supervision or interventions to prevent further incidents. The facility failed to implement its own policies for assessment, care planning, and monitoring, resulting in a deficiency related to resident protection from sexual abuse.
The facility failed to properly store and secure medications, as medications were left unattended in residents' rooms and not properly labeled or dated in storage areas. A resident with cognitive impairment was found self-administering medication without supervision or proper documentation. Additionally, expired medications and unlabeled insulin pens were found in the medication room. Staff confirmed these practices were against facility policy.
The facility failed to calibrate thermometers and improperly stored food in resident nourishment refrigerators, leading to deficiencies. The Dietary Manager did not calibrate thermometers before use, and observations revealed unlabeled, undated, and employee food items in resident refrigerators, contrary to facility policy. These actions were confirmed by staff and management, indicating non-compliance with food safety standards.
A resident with severe malnutrition and cognitive impairment did not receive their meal tray on time, unlike other residents at the same table. The facility's policy requires prompt meal service, but the resident's tray was delayed until the Lead Dietitian was informed.
The facility failed to maintain a sanitary environment, as observed in two residents' rooms. One room had straws, a white powdery substance, and crumbs on the floor, while another had dried brown substances in the bathroom. Despite multiple observations, the conditions remained unchanged, and both the Administrator and Housekeeping Supervisor confirmed the lack of cleaning.
The facility failed to provide necessary ADL assistance for three residents, including diabetic nail care and scheduled bathing. A resident's nails were observed to be long and dirty despite requests for care, and two residents did not receive their scheduled showers or bed baths on multiple occasions. The DON confirmed the lack of documentation for these activities, indicating non-compliance with care plans.
The facility failed to maintain infection control practices and proper medication administration protocols. A resident in contact isolation was assisted by CNAs without PPE, contrary to policy. Additionally, an LPN and RN did not perform hand hygiene or use clean barriers during medication administration, and Enhanced Barrier Precautions were not followed for a resident with a PEG tube.
Failure to Timely Replace and Label Enteral Feeding and Water for PEG Tube
Penalty
Summary
Surveyors identified a deficiency in the facility’s care and services for a resident with a percutaneous endoscopic gastrostomy (PEG) tube when staff failed to replace and label enteral feeding and flush solutions in accordance with policy and clinical standards. The facility’s policy dated 10/15/2024 stated that feeding tubes would be maintained according to current clinical standards of practice with interventions to prevent complications. The resident involved was admitted with diagnoses including gastrostomy status, diabetes, seizures, and dementia, and a quarterly MDS assessment documented that the resident was rarely/never understood and required the use of a feeding tube. Physician’s orders directed continuous Jevity 1.5 enteral feeding at specified hourly rates and water flushes via PEG tube. During observations on multiple occasions over two consecutive days, surveyors noted that the water flush solution and tube feeding were not changed within a 24-hour period and were not properly labeled. On the first day of observation, a clear bag of water infusing via feeding pump was dated two days earlier. On the second day, Jevity 1.5 tube feeding infusing via pump was dated the previous morning, and a clear bag of fluids labeled only with “H2O” had no label, date, or time. In an interview, the DON stated that night shift staff were believed to be responsible for changing tube feeding bottles, tubing, and water, acknowledged that tube feedings and water should not be hung and infusing for more than 24 hours, and confirmed that all tube feedings and water should be labeled and dated.
Failure to Obtain and Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to obtain and follow physician orders for oxygen therapy and to adhere to its own oxygen administration policy for two residents. Facility policy required that oxygen be administered only under a physician’s order, at the ordered rate and route, and that oxygen tubing and cannulas be changed weekly and as needed. For one resident with COPD, interstitial pulmonary disease, atrial fibrillation, and dependence on supplemental oxygen, the physician’s order specified continuous oxygen at 2 L/min via nasal cannula. However, observations on multiple occasions showed the oxygen concentrator set at 3.5 L/min, and the tubing/cannula was not dated. The medical record for this resident contained no physician order for oxygen tubing/cannula changes in December 2025 and January 2026, and the MAR/TAR for those months showed no documentation that the tubing/cannula had been changed, despite ongoing daily oxygen administration. For a second resident with dementia, heart disease, heart failure, hyperlipidemia, and hypertension, multiple entries on the Weights and Vitals Summary and skilled nursing notes documented the use of oxygen via nasal cannula over several months, and nursing documentation referenced oxygen saturations obtained while the resident was on oxygen. Despite this, there was no physician order for oxygen therapy in the physician orders for September 2025 or December 2025, and the resident’s care plan did not include oxygen therapy. Observations over two days showed the resident receiving oxygen via nasal cannula at settings between 2 and 2.5 L/min, while nursing staff verbally indicated the order was for 2 L/min and that the resident had been on oxygen since approximately July. A physician order for oxygen at 2 L/min PRN was not obtained until January 7, 2026, after which the concentrator was still observed set between 2 and 2.5 L/min. In interviews, the DON confirmed that oxygen should not be administered without an order, that residents on oxygen should have orders for tubing/cannula changes, and that oxygen should be administered at the prescribed rate.
Failure to Prevent Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect two residents' rights to be free from sexual abuse, resulting in a deficiency cited at F-600. One resident with severe cognitive impairment and a history of dementia-related behaviors, including hypersexuality and confusion, displayed inappropriate and unwanted behaviors toward other residents. Despite staff observing these behaviors and reporting them to nursing leadership, no immediate interventions were implemented to monitor or manage the resident's hypersexual behaviors while awaiting the administration and evaluation of prescribed medication. Documentation shows delays in medication administration and a lack of consistent monitoring or supervision during this period. Subsequently, a certified nursing assistant discovered the two cognitively impaired residents, both lacking capacity to consent, engaged in sexual activity in a resident's room. Interviews with staff and family members confirmed that both residents would have been unable to consent and that the incident likely caused psychosocial trauma. Staff interviews revealed that there was no increased monitoring or supervision in place prior to the incident, and care plan interventions were limited to redirection and attempts to keep the resident engaged, without specific measures to prevent inappropriate sexual contact. Medical records and staff documentation indicated ongoing sexually inappropriate behaviors, wandering, and delusional thinking by the resident both before and after the incident. Observations during the survey also revealed continued affectionate and inappropriate touching toward other male residents, with staff unable to provide consistent supervision. The facility's policy required identification, assessment, care planning, and monitoring for residents with behaviors that could lead to conflict or neglect, but these steps were not adequately implemented, resulting in a failure to prevent sexual abuse between vulnerable residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and security of medications, as evidenced by medications being left in residents' rooms and not being properly labeled or dated in medication storage areas. Resident #217, who was cognitively intact, was found with a pill cup containing medications left unattended in her room. The Licensed Practical Nurse (LPN) admitted to leaving medications for the resident to take at her convenience, despite the facility's policy against leaving medications unattended with residents. The Director of Nursing (DON) confirmed that medications should not be left unattended. Resident #267, who had moderate cognitive impairment, was observed self-administering a nebulizer treatment without staff supervision and without an assessment or order to self-administer medications. The LPN confirmed that the resident should not have been self-administering medication, and the medication administration was not documented on the Medication Administration Record (MAR). The DON and the Administrator both confirmed that medications should be documented when administered. Additionally, the facility failed to ensure that medications were properly labeled and not expired. An unlabeled insulin pen was found in a plastic bag with a resident's name written on the outside, and expired medications were found in the Nurse's Station #1 Medication Room. The DON confirmed that insulin pens should be labeled and that expired medications should not be present in the medication room.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to its policies regarding food safety and storage, leading to several deficiencies. The facility's policy required thermometers to be calibrated to ensure food safety, but the Dietary Manager admitted to not calibrating the thermometers before use, which was confirmed by District Manager A. This failure to calibrate thermometers could result in serving food at unsafe temperatures. Additionally, the facility's policy mandated that all food brought in by family or visitors be labeled and dated, yet observations revealed unlabeled and undated food items in the resident nourishment refrigerators. Further observations showed that staff beverages were improperly stored in the resident nourishment refrigerators, which is against the facility's policy. An LPN confirmed that employee food should not be stored in these refrigerators. The presence of unlabeled, undated, and employee food items in the resident nourishment refrigerators was confirmed by both District Manager B and District Manager A. These actions and inactions demonstrate a lack of compliance with the facility's food safety and storage policies, potentially compromising the safety and quality of food provided to residents.
Resident Meal Service Delay
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by a resident not receiving their meal tray in a timely manner alongside other residents at the same dining table. The facility's policy on Resident Meal Service mandates that each resident should receive prompt meal service and appropriate assistance. However, during an observation in the main dining room, it was noted that the resident did not receive their meal tray while other residents at the table were served and began eating. The resident involved was admitted with diagnoses including Severe Protein-Calorie Malnutrition and Neurocognitive Disorder, and had a care plan indicating a risk for altered nutritional status. The resident's medical record specified a therapeutic diet with fortified foods and required assistance with eating due to moderate cognitive impairment. Despite these needs, the resident's meal tray was delayed, and the issue was only rectified after the Lead Dietitian was notified, resulting in the resident receiving their tray significantly later than their tablemates.
Failure to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for its residents, as evidenced by the conditions observed in two resident rooms. In one instance, a resident's room was found to have two straws, a white powdery substance, a torn salt packet, and crumbs scattered on the floor. This resident was confined to bed, indicating a potential inability to address the cleanliness issues themselves. Despite multiple observations throughout the day, the room remained in the same unclean state, and both the Administrator and Housekeeping Supervisor confirmed that the room had not been cleaned recently. In another case, a resident's bathroom was observed to have dried dark brown spots on the floor and a dried brown substance on the outside of the toilet, back of the toilet tank, and on the door frame. The resident had complained about the odor and cleanliness of the room. Despite the presence of a Wet Floor sign later in the day, the unsanitary conditions persisted. Both the Administrator and Housekeeping Supervisor acknowledged that the bathroom had not been cleaned, with the Housekeeping Supervisor describing the situation as unacceptable.
Failure to Provide ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for three residents, specifically in the areas of incontinent care, bathing, and grooming. Resident #8, who was cognitively intact and dependent on staff for personal hygiene, did not receive diabetic nail care as ordered. Observations revealed that Resident #8's fingernails were long and dirty, and the resident expressed a desire to have them cut and to be shaved. Despite the physician's orders and the resident's request, the Director of Nursing confirmed that the necessary care had not been provided. Additionally, Resident #47 and Resident #57, both cognitively intact and requiring assistance with bathing, did not receive their scheduled showers or bed baths on multiple occasions. The care plans for these residents specified their bathing preferences and assistance needs, yet the Bath Reports showed several missed bathing sessions. The Wound Care Nurse and the Director of Nursing confirmed the lack of documentation for these bathing activities, indicating a failure to adhere to the residents' care plans and facility policies.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to maintain infection prevention and control practices for several residents, leading to deficiencies in care. For Resident #34, who was in contact isolation due to an ESBL infection in the urine, Certified Nursing Assistants (CNAs) were observed assisting the resident without wearing the required personal protective equipment (PPE), such as gowns and gloves. This was despite the facility's policy on transmission-based precautions, which mandates the use of PPE to prevent the spread of infections. Interviews with the Registered Nurse and Infection Control Preventionist confirmed that the appropriate PPE should have been used. Additionally, the facility did not adhere to proper medication administration protocols for multiple residents. Observations revealed that a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) failed to perform hand hygiene and did not use clean barriers while administering medications to residents. Specifically, RN G used a contaminated alcohol wipe on a resident's cheek and did not follow Enhanced Barrier Precautions for a resident with a PEG tube. The Director of Nursing confirmed that these actions were against the facility's procedures, which require hand hygiene and the use of clean barriers during medication administration.
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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