Legacy Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Manchester, Tennessee.
- Location
- 811 Keylon Street, Manchester, Tennessee 37355
- CMS Provider Number
- 445383
- Inspections on file
- 17
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Legacy Health And Rehab during CMS and state inspections, most recent first.
The facility failed to provide the required 8 hours of RN coverage per day on multiple occasions, particularly on weekends, due to a recent resignation. Staff confirmed the inconsistency in RN coverage, and the administration acknowledged the deficiency.
The facility did not update the daily nurse staffing information as required by their policy. The posted staffing information was outdated, showing the schedule for a previous date rather than the current staff. The DON stated that the Unit 1 Charge Nurse was responsible for updating the staffing sheet.
The facility failed to provide hot water at a kitchen handwashing sink and did not maintain kitchen equipment and floors in a sanitary condition. Observations showed food debris on kitchen equipment and the floor, and the Dietary Manager confirmed the lack of cleanliness and hot water availability.
A resident with dementia and a high fall risk experienced an unwitnessed fall, but the facility failed to notify the resident's family, physician, and DON as required by policy. The DON confirmed that staff are expected to make these notifications immediately, but acknowledged that some staff delay until morning if no injury is present.
An LPN failed to secure medications in a locked location, leaving a bottle of Valproic Acid unsecured on a medication cart. This action was against the facility's policy, which requires medications to be stored in locked compartments. The incident involved a resident with Type 2 Diabetes, Schizophrenia, and Anxiety Disorder.
A resident with multiple diagnoses, including Multiple Sclerosis and moderate cognitive impairment, was found to have their call light out of reach on multiple occasions. Despite the facility's policy requiring call lights to be within easy reach, observations and staff interviews confirmed the call light was inaccessible, leading to a deficiency in accommodating the resident's needs.
A facility failed to provide a resident with information about their right to formulate an advance directive upon admission. The resident, with severe cognitive impairment and multiple diagnoses, did not receive the necessary information, and the Advanced Directive Acknowledgement form was not signed. The Admissions Director confirmed the oversight.
The facility failed to maintain a safe, clean, and homelike environment for several residents, as observed in multiple rooms with chipped paint, rust-like substances, and dirty residues. These deficiencies were confirmed by the Assistant Administrator, Housekeeping Director, and Maintenance Director, who acknowledged the lack of compliance with the facility's policy.
The facility failed to accurately complete MDS assessments for three residents regarding anticoagulant use and active diagnoses. A resident with Pulmonary Embolism and Depression was prescribed Eliquis, but it was not recorded in the MDS. Another resident with severe cognitive impairment and Atrial Fibrillation also had Eliquis omitted from their MDS. Additionally, a resident with Bipolar Disorder and Venous Thrombosis had both their anticoagulant medication and active diagnoses inaccurately captured. These deficiencies were confirmed by the MDS Coordinators.
A facility failed to develop a comprehensive care plan for a resident with a colostomy. Despite the resident being cognitively intact and requiring moderate assistance for ADLs, the care plan did not include specific measures for colostomy care, even though physician orders were in place. This oversight was confirmed by the Unit Manager.
A facility failed to update a resident's care plan to reflect a new fall intervention after the resident, who was moderately cognitively impaired and dependent on staff for transfers, fell from the bed. The intervention involved replacing an air mattress with a regular mattress, but the care plan still indicated the use of an air mattress. The oversight was confirmed by the Unit Manager/LPN MDS Coordinator, contrary to the facility's policy.
Failure to Provide Minimum RN Coverage
Penalty
Summary
The facility failed to provide the required minimum of 8 hours per day of Registered Nurse (RN) coverage on multiple occasions. A review of the facility's Payroll Based Journal (PBJ) report from 10/1/2023 to 12/31/2023 revealed that there was no RN coverage on several weekends, including specific Saturdays and Sundays. Additionally, the facility's daily staffing posting sheets and time clock punches indicated insufficient RN coverage on various other days, with some days having as little as 1.13 hours of RN coverage. Interviews with facility staff, including the Staff Development Coordinator/Infection Control Nurse, confirmed the lack of consistent RN coverage, particularly on weekends. The RN who was scheduled to work on Saturdays and Sundays had recently quit, and the facility was in the process of hiring a replacement. The Administrator, Assistant Administrator, Director of Nursing, and the Controller acknowledged the facility's failure to meet the minimum RN coverage requirement.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate daily nurse staffing information, as required by their policy. The policy, revised in July 2016, mandates that the facility must post the number of nursing personnel responsible for providing direct care to residents for each shift on a daily basis. However, during an observation on April 8, 2024, at 7:40 AM, it was noted that the staffing information displayed was outdated, showing the staff scheduled for April 5, 2024, rather than the current staff present on April 8, 2024. In an interview conducted on April 10, 2024, at 2:35 PM, the Director of Nursing indicated that the responsibility for posting the daily staffing sheet lay with the Unit 1 Charge Nurse. This oversight in updating the staffing information led to the deficiency noted by the surveyors.
Deficiencies in Kitchen Sanitation and Handwashing Facilities
Penalty
Summary
The facility failed to ensure hot water was available for staff to wash and sanitize their hands at one of the two kitchen handwashing sinks. During an observation and interview with the Dietary Manager (DM), it was noted that the sink, which had been converted from an eye wash station, did not have hot water connected. The DM confirmed that it was expected for hot water to be available for kitchen staff use, but it was not. Additionally, the facility did not maintain kitchen equipment and floors in a sanitary manner. Observations in the food preparation area revealed thick layers of sticky, black food debris on the outer door, bottom edge, and temperature dials of the food warmer. In the dishwashing area, food debris, a plastic cup, and a plastic fork were found scattered on the floor beneath the dishwasher on consecutive days. The DM acknowledged that the kitchen equipment and floors were not cleaned as expected, which was supposed to be done daily and deep cleaned weekly.
Failure to Notify After Resident Fall
Penalty
Summary
The facility failed to ensure appropriate notifications were conducted following a fall involving a resident diagnosed with Dementia with Behavioral Disturbance, Cognitive Communication Deficit, Depression with Psychotic Features, Anxiety, Hypotension, and Urinary Tract Infection. The resident, who was admitted with a high fall risk score, experienced an unwitnessed fall on 1/30/2024 at 1:00 AM. Despite the facility's policy requiring notification of the resident's family, attending physician, Director of Nursing Services, and the Nursing Supervisor on duty, there was no documentation indicating that these notifications were made. The Director of Nursing (DON) confirmed during an interview that staff are expected to notify the necessary parties of a resident's fall, regardless of the time of day or whether an injury occurred. However, the DON acknowledged that some staff might delay notifications until the morning if no injury is present, which was the case for this incident. The lack of notification was confirmed through a review of the resident's progress notes, history and physical note, and event report, all of which showed no evidence of the required notifications being made.
Medication Security Lapse
Penalty
Summary
The facility failed to ensure that medications were secured in a locked location, as required by their policies. During an observation, an LPN prepared medications for a resident with diagnoses including Type 2 Diabetes, Schizophrenia, and Anxiety Disorder. The LPN left the medication room without locking the door and left a bottle of Valproic Acid unsecured on top of the medication cart. This action was contrary to the facility's policy, which mandates that medications be stored in locked compartments and that no medications are left on top of the cart. The LPN confirmed during an interview that the bottle of Valproic Acid was left unsecured. The Director of Nursing also stated that it was the facility's expectation for medications to be secured and locked. This incident highlights a failure to adhere to the facility's medication storage policies, which are designed to ensure the safety and security of medications within the facility.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure the call light was within reach for a resident, leading to a deficiency in accommodating the needs and preferences of the resident. The facility's policy, dated March 2021, requires that the call light be within easy reach when a resident is in bed or confined to a chair. However, during observations and interviews, it was found that the call light for a resident with multiple diagnoses, including Multiple Sclerosis and moderate cognitive impairment, was not accessible. The resident, who required substantial assistance with personal hygiene, was observed seated in a reclining chair with the call light clipped to the privacy curtain and later draped over the side of the bed, both times out of reach. Interviews with staff, including an LPN and a CNA, confirmed that the call light was not within the resident's reach and was not accessible for use. The Director of Nursing also acknowledged that the facility's expectation was for call lights to be within reach when residents are in bed or sitting in chairs. Despite this expectation, the facility did not ensure the call light was accessible for the resident's use, resulting in a failure to meet the resident's needs and preferences as outlined in the care plan.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide a resident with information regarding their right to formulate an advance directive upon admission. The facility's policy, revised in December 2016, mandates that residents be given written information about formulating an advance directive upon admission. However, for one resident, who was admitted with severe cognitive impairment and multiple diagnoses including Schizoaffective Disorder, Bipolar Type, Dementia, Psychotic Disorder with Hallucinations, Anxiety Disorder, and Hypertension, this information was not provided. The resident's admission Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of 7, reflecting severe cognitive impairment. The Advanced Directive Acknowledgement form for this resident was not signed by either the resident or their representative upon admission. During an interview, the Admissions Director confirmed that neither the resident nor their representative received the necessary information about formulating an advance directive at the time of admission.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for six residents across one of the four hallways observed. The facility's policy, revised in February 2021, mandates that residents are provided with a safe, clean, and homelike environment. However, observations revealed that the rooms of several residents had chipped paint, rust-like substances, and dirty residues, which were not in compliance with the facility's policy. Resident #30's room was observed on multiple occasions to have a bathroom door frame with missing, chipped paint and a rust-like substance where the paint was missing. The floor around the toilet had a brownish/black dirty residue, and the closet and entry door frames also had chipped paint. Similar conditions were noted in the shared bathroom of Residents #25 and #50, where the bathroom and closet door frames had chipped paint and rust-like substances, and the floor around the toilet was dirty. Additionally, Resident #25's bedside table had chipped wood, and a dresser had a missing handle. Other residents, including Residents #3, #35, and #17, also experienced similar deficiencies. Resident #3's room had a bathroom door frame with chipped paint and rust, a dresser with missing handles, and a broken nightstand. Resident #35's room had a stained toilet seat, chipped paint, and a dresser with missing paint and a knob. Resident #17's room had a bathroom door frame with chipped paint and rust, and a dresser with missing paint. These observations were confirmed by the Assistant Administrator, Housekeeping Director, and Maintenance Director, who acknowledged that the rooms were not maintained in a safe, clean, and homelike environment.
Inaccurate MDS Assessments for Anticoagulant Use and Diagnoses
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for three residents regarding anticoagulant medication use and active diagnoses. Resident #31, who was admitted with conditions including Pulmonary Embolism and Depression, was prescribed Eliquis, an anticoagulant, but this was not recorded in the MDS assessment. The Licensed Practical Nurse (LPN) MDS Coordinator confirmed the omission during an interview. Similarly, Resident #20, with severe cognitive impairment and conditions such as Heart Failure and Atrial Fibrillation, was also prescribed Eliquis, but the medication was not documented in the MDS assessment. The Registered Nurse (RN) MDS Coordinator acknowledged this oversight. Resident #14, who had diagnoses including Bipolar Disorder, Anxiety Disorder, and Venous Thrombosis, was also prescribed Eliquis. However, the MDS assessment failed to capture both the anticoagulant medication and the active diagnoses of Depression, Anxiety, and Bipolar Disorder. The RN MDS Coordinator confirmed these inaccuracies during an interview. These deficiencies indicate a failure in accurately completing the MDS assessments, which are crucial for ensuring appropriate care and treatment for residents.
Failure to Develop Comprehensive Care Plan for Colostomy
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a colostomy, which was identified during a review of the facility's care planning practices. The facility's policy requires a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's needs. However, the care plan for a resident admitted with multiple diagnoses, including a colostomy, did not include any specific plan related to the colostomy. The resident was cognitively intact and required moderate assistance for activities of daily living, as indicated by the admission Minimum Data Set. Despite having physician orders for colostomy care, the comprehensive care plan was not updated to reflect this need, as confirmed by the Unit Manager during an interview.
Failure to Update Care Plan After Fall Intervention
Penalty
Summary
The facility failed to revise a comprehensive care plan to reflect a new fall intervention for a resident who was moderately cognitively impaired and dependent on staff assistance for transfers. The resident, who had a history of falls, was admitted with diagnoses including abnormalities of gait and mobility, muscle weakness, and a need for personal care. Following a fall incident on February 16, 2024, where the resident fell from the bed while reaching for a drink, an immediate intervention was implemented to replace the air mattress with a regular mattress to prevent further falls. Despite this intervention, the resident's care plan, last revised on April 5, 2024, still indicated the use of an alternating air mattress and did not reflect the change to a regular mattress. During interviews, the Unit Manager/LPN MDS Coordinator confirmed that the care plan had not been updated to include the new fall intervention, which was against the facility's policy that care plans should be revised as residents' conditions change. This oversight was identified during an observation and interview conducted on April 9, 2024.
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 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.
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.
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 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.
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.
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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