Huntsville Post-acute And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntsville, Tennessee.
- Location
- 287 Baker Street, Huntsville, Tennessee 37756
- CMS Provider Number
- 445288
- Inspections on file
- 22
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Huntsville Post-acute And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to report COVID-19 infections for seven residents to the local health department in a timely manner. Additionally, two COVID-19 positive residents were allowed to participate in a smoking activity with two COVID-19 negative residents, violating infection control practices. A CNA provided care to a COVID-19 positive resident without proper PPE, and staff did not offer hand hygiene assistance to several residents before meals.
A resident with an indwelling urinary catheter had their dignity compromised when the facility failed to cover their urinary catheter collection bag, leaving it visible from the room's door. The facility's policy requires such bags to be placed in privacy bags, but this was not adhered to, as confirmed by an LPN and the DON.
A resident with cognitive impairments and hemiplegia was found to have a spiral fracture of the distal tibia, which the facility failed to report as an injury of unknown origin. Despite the facility's policy requiring such injuries to be reported, the staff assumed the injury was caused by the resident's leg getting caught under a wheelchair pedal, although there was no witness or documentation to support this. The resident, unable to communicate due to expressive aphasia, had no known incidents or falls, and the facility's investigation lacked evidence to explain the injury.
A resident in an LTC facility, who required assistance due to blindness and other conditions, did not receive proper nail care as part of ADL. Despite the facility's policy requiring routine nail cleaning, observations showed the resident had long, unclean nails. Staff interviews confirmed that nail care was supposed to be done during bathing, but the resident's needs were neglected.
A resident was found with unsecured smoking supplies and medications at their bedside, contrary to the facility's policy requiring such items to be stored securely. The resident, who was receiving treatment for COPD and nicotine dependence, admitted to smoking outside the facility with their daughter, who had brought the cigarettes and lighter. Staff interviews revealed a lack of awareness about the resident's possession of these items, highlighting a deficiency in maintaining a safe environment.
The facility failed to properly store nebulizer masks for two residents, leading to a deficiency in respiratory care. A resident with COPD and other conditions was observed with an uncovered nebulizer mask, confirmed by the DON. Another resident, also with COPD, was seen multiple times with an uncovered mask, confirmed by both the resident and an LPN. The DON acknowledged the staff's failure to follow the facility's policy requiring masks to be covered when not in use.
A facility's ineffective QAPI program led to a deficiency when medications were found at a resident's bedside, despite the resident not being assessed for self-administration. The resident, with multiple diagnoses including COPD, was cognitively intact. The facility had previously been cited for a similar issue, and despite implementing a Resident Advocate Program to prevent such occurrences, the medications were not observed during routine checks.
A resident with a history of medical and psychological conditions was found hoarding medications, including prescribed and over-the-counter drugs, due to the facility's failure to implement a comprehensive care plan. Despite being cognitively intact, the resident engaged in manipulative behaviors involving medication, which were not adequately addressed. The facility's policy required comprehensive care plans, but the resident's plan lacked updates to address these behaviors, posing a risk to the resident and others.
A resident with a history of various medical conditions was able to hoard medications due to inadequate supervision during medication administration. The resident's manipulative behavior, including delaying the medication process, led to medications being left at the bedside or not properly observed by staff. This resulted in the discovery of a significant quantity of hoarded pills, placing the resident and others at risk.
A resident in an LTC facility was able to hoard medications due to the failure of medication nurses to ensure the resident swallowed all medications when administered. Despite being cognitively intact, the resident was found with medications in their room on multiple occasions. The facility's policy required nurses to observe residents swallowing medications, but this was not consistently followed, leading to inaccurate documentation and an Immediate Jeopardy situation.
A resident was found self-administering medications without an assessment or physician's order, contrary to facility policy. Despite being cognitively intact, the resident hoarded medications, including pain medication and muscle relaxants, over time. Staff interviews revealed that medications were left with the resident without proper authorization, and the facility failed to follow its self-administration policy.
The facility failed to maintain a homelike environment in several resident rooms due to unclean wheelchairs and personal furniture, resulting in foul odors. The DON confirmed that the cleaning schedule for incontinent residents' wheelchairs was not followed, and personal recliners were not adequately cleaned as part of the housekeeping schedule.
Infection Control and Reporting Deficiencies
Penalty
Summary
The facility failed to report new COVID-19 infections for seven residents to the local health department in a timely manner. The Director of Nursing (DON) acknowledged that the positive COVID-19 test results for these residents were not reported until ten days after the tests were conducted. This delay in reporting is a violation of the state Department of Health's requirements for reporting communicable diseases, including COVID-19. Additionally, the facility did not adhere to appropriate infection control practices by allowing two COVID-19 positive residents to participate in a smoking activity with two COVID-19 negative residents. During the observation, it was noted that the residents were not wearing masks and were in close proximity to each other, which contradicts the facility's policy that residents with confirmed COVID-19 should not participate in communal activities and should remain in their rooms unless medically necessary. The facility also failed to ensure proper infection control practices were followed for a resident under transmission-based precautions. A CNA was observed providing care to a COVID-19 positive resident without wearing the required personal protective equipment (PPE), such as a gown, gloves, and eye protection. Furthermore, staff did not offer hand hygiene assistance to several residents before meals, which is a breach of the facility's hand hygiene policy.
Failure to Cover Urinary Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to protect the dignity of a resident by not covering a urinary catheter collection bag. The facility's policy on promoting resident dignity requires that urinary catheter bags be placed in privacy bags. However, during an observation, it was noted that the urinary collection bag of a resident was uncovered and visible from the door of the resident's room. This observation was confirmed by an LPN who acknowledged that the bag was not covered with a dignity bag. The resident involved was admitted with diagnoses including Bladder Neck Obstruction, Benign Prostatic Hyperplasia, and Major Depressive Disorder. The resident was cognitively intact, as indicated by a score of 15 on the Brief Interview for Mental Status assessment. The Director of Nursing confirmed that it was her expectation for all urinary catheters to have privacy bags, and acknowledged that the resident's dignity was compromised when the catheter bag was left uncovered.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the state designated authorities for a resident, identified as Resident #24, who was found to have a comminuted spiral fracture of the distal tibia. The facility's policy requires that all unexplained injuries be investigated and reported if they meet certain criteria, such as being suspicious due to the extent or location of the injury. Despite these requirements, the facility did not report the injury, as they believed it was caused by the resident's leg getting caught under the wheelchair pedal, although there was no witness or documentation to support this claim. Resident #24, who has a history of cerebrovascular accident, hemiplegia, and cognitive impairments, was noted to have pain, redness, and swelling in the right lower extremity. An x-ray confirmed a spiral fracture, and the resident was sent to the emergency room for further evaluation. The resident, who has expressive aphasia, was unable to communicate the cause of the injury, and staff interviews revealed no known incidents or falls that could explain the fracture. The facility's investigation did not find any witnesses or evidence to support the assumption that the injury was caused by the wheelchair pedal. Interviews with the facility's Administrator, DON, and Risk Manager revealed that the injury was not reported because they believed it was not of unknown origin, based on the resident's history of not using the wheelchair foot pedal. However, the investigation lacked documentation or witness statements to substantiate this belief. The facility's failure to report the injury as required by their policy and state regulations constitutes a deficiency in their handling of potential abuse or neglect cases.
Failure to Provide Nail Care During ADL
Penalty
Summary
The facility failed to provide adequate nail care during Activities of Daily Living (ADL) for a resident who required assistance. The facility's policy on ADL care, which includes nail care, mandates routine cleaning and inspection of nails by nursing staff. However, observations and interviews revealed that a resident, who was cognitively intact but required assistance due to blindness and other medical conditions, had long, rough fingernails with a brown substance underneath. The resident expressed a desire to have his nails clipped, indicating that staff had not attended to this need recently. The resident's medical records showed that he had not received a bath since a specific date, and during multiple observations, his nails remained uncleaned. Interviews with staff, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), confirmed that nail care was supposed to be part of the bathing routine. The Director of Nursing (DON) acknowledged that nail care should be performed during showers and confirmed that the resident was not receiving thorough ADL care, as evidenced by the neglected nail condition.
Failure to Secure Smoking Supplies and Medications
Penalty
Summary
The facility failed to ensure that smoking supplies and medications were properly secured for a resident, leading to a deficiency in maintaining a safe environment. The facility's policy mandates that all smoking products, such as cigarettes and lighters, be kept at the nurse's station and not in the possession of residents. Additionally, medications are to be stored in locked compartments unless a resident has been assessed as safe to self-administer. However, during an observation, it was found that a resident had a cigarette lighter, a pack of cigarettes, and medications at their bedside, which were not secured as per the facility's policy. The resident in question was admitted with multiple diagnoses, including COPD and nicotine dependence, and was receiving treatment with inhaled medications and a nicotine patch for smoking cessation. Despite the resident's care plan indicating the use of tobacco products, the resident was not currently using tobacco products according to the Minimum Data Set assessment. However, during an interview, the resident admitted to smoking half a cigarette outside the facility with their daughter, who had brought the cigarettes and lighter during a visit. The facility's Director of Nursing confirmed the presence of these items at the resident's bedside and removed them, reiterating the facility's smoking policy to the resident. Interviews with various staff members, including the Director of Nursing, Licensed Practical Nurse, Certified Nursing Assistant, and Activities Director, revealed a lack of awareness regarding the resident's possession of smoking supplies and medications. The staff confirmed that the resident had not participated in smoke times and that smoking supplies were supposed to be secured in the Activities office. The Social Services Director also confirmed that the resident's stepdaughter had brought the cigarettes and lighter during a visit, contrary to the facility's policy. The facility's failure to secure smoking supplies and medications as per their policy resulted in a deficiency in ensuring a safe environment for residents.
Improper Storage of Nebulizer Masks for Residents
Penalty
Summary
The facility failed to ensure proper storage of nebulizer masks for two residents, leading to a deficiency in respiratory care. Resident #11, who was admitted with conditions including Pneumonia, COPD, and Chronic Respiratory Failure, was observed with a nebulizer mask lying uncovered on the bedside table. This was confirmed by the Director of Nursing (DON) during an observation and interview, who acknowledged that the mask should have been stored in a plastic bag when not in use, as per the facility's policy. Similarly, Resident #40, who has diagnoses including COPD and is cognitively intact, was observed on multiple occasions with an uncovered nebulizer mask on the bedside table. Both the resident and a Licensed Practical Nurse (LPN) confirmed the mask was not stored according to policy. The DON reiterated that the expectation was for masks to be covered when not in use, confirming the staff's failure to adhere to the respiratory equipment policy.
Medication Safety Deficiency Due to Ineffective QAPI Program
Penalty
Summary
The facility failed to maintain an effective and ongoing Quality Assurance Performance Improvement (QAPI) program, resulting in a deficiency when medications were found at a resident's bedside. The facility's policy requires that medications be secured unless a resident has been assessed as safe to self-administer. However, during an observation, medications including an Albuterol Sulfate inhaler and a vial of Budesonide Inhalation Suspension were found on the bedside table of a resident who had not been evaluated for self-administration. This oversight occurred despite the facility's implementation of a Resident Advocate Program (RAP) to prevent such issues. The resident involved was admitted with multiple diagnoses, including Chronic Obstructive Pulmonary Disease (COPD) and was cognitively intact according to a recent assessment. The facility had previously been cited for a similar deficiency at an Immediate Jeopardy level, indicating a serious risk to resident safety. Despite the RAP program's daily checks, the medications were not observed by the resident's advocate prior to the survey team's arrival, highlighting a lapse in the facility's QAPI program and its processes to ensure medication safety.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, leading to a situation of Immediate Jeopardy. The resident, who had a history of various medical and psychological conditions, was found hoarding medications, including both prescribed and over-the-counter drugs. Despite being cognitively intact, the resident engaged in manipulative behaviors involving medication, such as hoarding and cheeking, which were not adequately addressed in the care plan. The deficiency was identified when the resident was discovered with medications at their bedside, and further investigations revealed that the resident had been ordering and receiving over-the-counter medications online. The facility's policy required comprehensive care plans to include measurable objectives and timeframes to meet residents' needs, but the care plan for this resident lacked updates or revisions to address the manipulative behaviors and the accumulation of medications. Interviews with staff, including the DON and Medical Director, confirmed that the facility did not implement appropriate interventions following the discovery of medications at the resident's bedside. The failure to address these issues in the care plan posed a risk not only to the resident but also to other residents in the facility, as there was a possibility of harm if other residents accessed the hoarded medications.
Inadequate Supervision During Medication Administration Leads to Medication Hoarding
Penalty
Summary
The facility failed to ensure adequate supervision during medication administration, leading to a situation where a resident was able to hoard medications. This deficiency was identified through medical record reviews, facility documentation, observations, and interviews. The resident involved had a history of various medical conditions, including Psoriatic Arthritis, Chronic Obstructive Pulmonary Disease, Bipolar Disorder, and Anxiety Disorder. Despite being cognitively intact, the resident was found to have hoarded medications on multiple occasions, which were discovered by staff during routine checks and cleaning activities. The resident's behavior included delaying the medication administration process, which sometimes led to medications being left at the bedside or not being properly observed by the nursing staff. This behavior was noted to be manipulative, as the resident would take a long time to consume medications, creating opportunities to hide or hoard them. On several occasions, staff found medications in the resident's room, including a significant quantity of pills hidden in various places, such as a headphone case and a duffle bag. The resident denied any suicidal or harmful intentions but admitted to hoarding medications over time. Interviews with staff revealed that the resident's medication administration process was time-consuming, often taking up to an hour, which contributed to the oversight. The staff acknowledged that the resident's manipulative behavior and the large number of medications to be administered created challenges in ensuring all medications were consumed. The facility's failure to provide adequate supervision during medication administration placed the resident and potentially other residents at risk, as there was a possibility of other residents accessing the hoarded medications.
Failure to Ensure Accurate Medication Administration
Penalty
Summary
The facility failed to provide a complete and accurate record of a resident's medication administration, which led to an Immediate Jeopardy situation. The medication nurses did not ensure that the resident swallowed all medications when administered, resulting in the Medication Administration Record (MAR) documenting medications as administered that were not actually taken by the resident. This oversight allowed the resident to hoard medications in their room, creating a potential risk for the resident and others in the facility. The resident involved had a history of multiple diagnoses, including Psoriatic Arthritis, Chronic Obstructive Pulmonary Disease, Bipolar Disorder, and Major Depressive Disorder. Despite being cognitively intact, as indicated by a high score on the Brief Interview for Mental Status (BIMS) assessment, the resident was found to have hoarded medications on multiple occasions. Nursing notes and psychiatric evaluations revealed that the resident had been keeping medications at their bedside and in other personal belongings, such as a headphone case and a duffel bag. Interviews with the Director of Nursing (DON) and other staff confirmed that the facility failed to accurately document the resident's medication administration. The resident reportedly had difficulty taking all medications at once and expressed concerns about potential retaliation if they reported not taking all medications. The facility's policy required nurses to observe residents swallowing medications, but this was not consistently followed, leading to the inaccurate documentation and the resident's ability to hoard medications.
Failure to Prevent Unauthorized Self-Administration of Medications
Penalty
Summary
The facility failed to prevent a resident from self-administering medications without an assessment and a physician's order. The facility's policy requires an interdisciplinary team assessment and a physician's order before a resident can self-administer medications. However, Resident #10 was found with medications at his bedside on multiple occasions without such an assessment or order. The resident, who was cognitively intact, had been hoarding medications, including pain medication, muscle relaxants, and medications for stomach acid, over a long period. The resident was admitted with multiple diagnoses, including Psoriatic Arthritis, Chronic Obstructive Pulmonary Disease, and Bipolar Disorder. Despite being cognitively intact, the resident accumulated medications in his room, which were discovered by staff during routine checks. The resident admitted to hoarding medications and expressed that it was a 'dumb idea.' The facility staff, including the Nurse Practitioner and the Director of Nursing, were aware of the situation but did not ensure that the resident was assessed for self-administration or that a physician's order was obtained. Interviews with facility staff revealed that the resident was allowed to keep certain medications in his room, such as anti-nausea medication and dietary enzymes, even though there was no order for self-administration. The Licensed Practical Nurse admitted to leaving medications with the resident if he did not take them during the medication pass. The Executive Director of Nursing confirmed that the facility did not follow its policy for self-administration of medications, leading to the deficiency.
Failure to Maintain a Homelike Environment Due to Unclean Furniture
Penalty
Summary
The facility failed to maintain a homelike environment free from odors in four resident rooms. Observations and interviews revealed that the source of the foul odors was urine-soaked wheelchairs and personal furniture, such as recliners and rock-n-go chairs, in the residents' rooms. The facility's document on wheelchair cleaning indicated that wheelchairs of incontinent residents were to be cleaned weekly, but there was no documentation of cleaning after September 1, 2023. This lapse in documentation and cleaning was confirmed by the Director of Nursing (DON) during interviews. The DON acknowledged that the system for documenting wheelchair cleaning had been neglected, as the log had been misplaced. Additionally, personal recliners were supposed to be part of the deep cleaning schedule by housekeeping, which was also not effectively implemented. The DON confirmed that the facility had failed to maintain a homelike environment in three resident rooms due to these oversights.
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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