Legacy Park Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Knoxville, Tennessee.
- Location
- 7424 Middlebrook Pike, Knoxville, Tennessee 37909
- CMS Provider Number
- 445105
- Inspections on file
- 20
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Legacy Park Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with an indwelling urinary catheter had their drainage bag left uncovered and visible to the public on multiple occasions, despite facility policy requiring dignity and privacy. Observations and staff interviews confirmed the bag was not covered, and the DON acknowledged that catheter bags should be concealed with a dignity or privacy cover.
A resident with Bipolar Disorder and Major Depressive Disorder, identified as having a PASRR Level II outcome for serious mental illness, was not accurately coded for this condition in a significant change MDS assessment. The RN MDS Coordinator and DON confirmed the assessment did not reflect the resident's PASRR status, despite active diagnoses and supporting documentation.
A resident with serious mental illness and a PASRR Level II outcome did not have this outcome addressed in their comprehensive care plan, despite facility policy requiring such inclusion. Both the RN MDS Coordinator and DON confirmed the omission during record review and interviews.
Staff did not follow hand hygiene protocols while distributing and setting up meal trays for multiple residents, including those with significant cognitive and physical impairments. Despite facility policy requiring hand hygiene during tray pass, a CNA was observed assisting several residents with their meals without performing hand hygiene between each interaction. This lapse was confirmed by both the CNA and the DON.
A resident in a LTC facility suffered harm due to a significant medication error involving Morphine Sulfate. The medication was incorrectly transcribed and administered on a scheduled basis instead of as needed, leading to the resident becoming semi-comatose with labored respirations and hypotension. The error was not caught by the facility's verification processes, and communication with hospice providers was lacking.
The facility failed to maintain complete and accurate medical records for several residents with indwelling urinary catheters. Documentation of urine output and catheter changes was missing for multiple residents, and a required communication tool was not completed for a resident transferred to the ER. Interviews with the DON and ADON confirmed these documentation deficiencies.
A resident in hospice respite care with multiple diagnoses received Morphine Sulfate at an incorrect frequency due to a transcription error by an LPN. The medication was administered routinely instead of as needed, contrary to the physician's order.
A hospice resident's Morphine order was transcribed incorrectly in the MAR, leading to incorrect dosing. The pharmacist failed to identify the error during the Medication Regimen Review. The resident, with multiple diagnoses, was supposed to receive Morphine 100 mg per 5 ml, but the MAR documented it as 20 mg per 5 ml, resulting in a lower dose being administered.
A resident's Morphine orders were incorrectly transcribed and administered on a scheduled basis instead of as needed, due to the facility's QAPI committee failing to identify and address quality deficiencies. The error was discovered when the resident's daughter noticed her mother was unusually drowsy. The facility did not conduct a thorough investigation or root cause analysis, and failed to implement an effective action plan, including comprehensive staff education and coordination with hospice and agency staff.
The facility failed to provide written information about the right to formulate an advance directive to 22 residents, as confirmed by medical record reviews and staff interviews. This deficiency affected residents with various cognitive abilities and medical conditions, and was acknowledged by the Nurse Liaison, Social Worker, and DON.
The facility failed to accurately complete MDS assessments for two residents. One resident's MDS inaccurately recorded a diagnosis of Pneumonia, which was not documented in their medical record. Another resident's oral health status was not assessed or documented accurately, despite notes indicating dental issues. The DON and MDS Coordinator confirmed these deficiencies.
A facility failed to resubmit a PASRR for a resident after a new diagnosis of Psychosis was identified. The resident, admitted with Dementia, Anxiety, Panic Disorder, and Adult Failure to Thrive, was found to have severe cognitive impairment. Despite the new diagnosis being recorded, the PASRR was not updated as required. This was confirmed by the DON during an interview.
The facility failed to update care plans with new interventions after falls for two residents. One resident with severe cognitive impairment had an unwitnessed fall, and another with moderate impairment fell from a wheelchair. Despite interventions being applied, the care plans were not revised to include these changes.
A resident, who was cognitively intact but dependent on staff for personal hygiene, was observed with long, dirty fingernails over several days. Despite the resident's request for nail trimming, staff failed to provide the necessary grooming care. Interviews with a CNA and an LPN confirmed the issue, and the DON acknowledged that nail care should be part of daily care.
The facility failed to secure chemicals and medications for two residents, leading to safety deficiencies. A resident had unsecured nail polish remover and air freshener, while another had an unsecured bottle of multivitamins. Both residents were cognitively intact but had not been assessed for self-administration of medications. Staff confirmed that these items should have been secured according to facility policy.
A facility failed to document the fluid restriction and consumption for a resident requiring dialysis care on the MAR, despite policy requirements. The resident, with conditions including Edema and End Stage Renal Disease, was on a 960 ml/day fluid restriction. Staff interviews confirmed the oversight, and the DON acknowledged the documentation failure.
The facility failed to develop dementia care plans for two residents diagnosed with severe cognitive impairment. Despite having diagnoses of dementia and Alzheimer's Disease, their care plans did not address these conditions. The DON and MDS Coordinator confirmed the oversight, acknowledging that dementia care plans were expected for residents with such diagnoses.
A resident with severe cognitive impairment was prescribed PRN Ativan for anxiety without a stop date or documented evaluation for continued use, contrary to the facility's policy limiting PRN psychotropic medications to 14 days. Interviews with facility staff confirmed the lack of evaluation and rationale for the medication's continued use.
The facility failed to properly label and secure medications, as well as remove expired supplies. An insulin pen was found unlabeled on a medication cart, and an LPN left a cart unlocked while administering medications. Controlled substances were left unsecured in a medication room, and expired supplies were available for use. The DON and Pharmacy Director confirmed these deficiencies.
A resident admitted with multiple health conditions, including anemia and diabetes, did not receive dental care as per the facility's policy. Despite having missing and discolored teeth and expressing a desire to see a dentist, there was no documentation of dental assessment or care since admission. The DON confirmed the lack of dental care documentation.
The facility did not properly contain garbage in one of its dumpsters, as observed when dumpster #6 was found without a plug. This was confirmed by the Certified Dietary Manager, contrary to the facility's trash disposal policy.
The facility did not obtain informed consent for the Pneumococcal vaccine for two residents, despite policy requirements. One resident had COPD, Chronic Respiratory Failure, and a history of Pulmonary Embolism, while another had Intestinal Obstruction, Chronic Bronchitis, Shingles, and Polyosteoarthritis. The Infection Preventionist confirmed the lack of informed consent documentation.
A facility failed to accurately transcribe a physician's order for a resident with serious health conditions, leading to a discrepancy between the prescribed Humulin R insulin and the incorrectly listed Humulin N on the MAR. The error was not detected until the resident's endocrinologist inquired about the accuracy of the MAR. Despite the error, the resident continued to receive the correct medication.
Failure to Maintain Resident Dignity by Leaving Catheter Bag Uncovered
Penalty
Summary
A deficiency occurred when a resident's right to dignity was not maintained, as evidenced by the facility's failure to ensure that an indwelling urinary catheter drainage bag was covered and not visible to the public. The facility's policy on resident rights, revised in February 2021, requires all residents to be treated with dignity. The resident involved was admitted and later readmitted with diagnoses including colon cancer, hypertension, and dementia, and was assessed as cognitively intact. The resident had an indwelling urinary catheter, as documented in the medical record and care plan. On two separate occasions, observations revealed that the resident's catheter bag was left uncovered and visible from the hallway while the resident was lying in bed. During interviews, both an LPN and the Director of Nursing confirmed that the catheter bag was not covered and acknowledged that all indwelling urinary catheters should be covered with a dignity bag or privacy cover. These findings were based on policy review, medical record review, direct observation, and staff interviews.
Inaccurate MDS Assessment for Resident with PASRR Level II Outcome
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident who was reviewed for MDS assessments. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manual and the facility's own policy, assessments must accurately reflect a resident's status, including the identification of serious mental illness as determined by a Level II Pre-admission Screening and Resident Review (PASRR). Medical record review showed that a resident admitted with diagnoses of Bipolar Disorder and Major Depressive Disorder had a PASRR Level II outcome indicating a serious mental illness. However, the significant change MDS assessment did not code for the PASRR Level II condition, despite the resident having active diagnoses of Bipolar Disorder and Depression. Further review of the resident's records, including a psychiatric nurse practitioner's note, confirmed ongoing treatment for bipolar disorder and depression. During interviews, the RN MDS Coordinator acknowledged that the MDS assessment was inaccurate and did not reflect the PASRR Level II outcome. The DON also confirmed that the facility did not ensure the accuracy of the significant change MDS assessment for this resident, as required by facility policy and regulatory guidelines.
Failure to Address PASRR Level II Outcome in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed all of a resident's needs, specifically omitting the required PASRR Level II outcome for a resident with serious mental illness. According to the facility's policy, the interdisciplinary team is responsible for creating a person-centered care plan that includes measurable objectives, timeframes, and addresses specialized services as recommended by PASRR. However, review of the medical record showed that the resident, who was admitted with diagnoses of Bipolar Disorder and Major Depressive Disorder and had a PASRR Level II outcome, did not have this outcome reflected in their care plan as of the most recent revision. During interviews, both the RN MDS Coordinator and the DON confirmed that the PASRR Level II outcome was not included in the resident's care plan, despite facility expectations and policy requirements. The omission was identified through policy review, medical record review, and staff interviews, confirming that the care plan did not comprehensively address the resident's mental health needs as required.
Failure to Perform Hand Hygiene During Meal Tray Distribution
Penalty
Summary
Facility staff failed to perform appropriate hand hygiene during the distribution and setup of meal trays for nine residents in one of three observed dining areas. According to the facility's own hand hygiene policy, staff are required to use proper hand hygiene during mealtimes, specifically when passing trays. Observations on a specified date revealed that a Certified Nursing Assistant (CNA) delivered and set up lunch trays for multiple residents without performing hand hygiene between each interaction. The residents involved had a range of medical conditions, including heart failure, dementia, chronic kidney disease, Parkinson's disease, diabetes, and other chronic illnesses. Their care plans indicated varying levels of cognitive impairment and physical dependency, with most requiring assistance or supervision with eating and personal hygiene. Despite these needs, the CNA did not follow hand hygiene protocols while assisting with meal setup, as confirmed by both direct observation and staff interviews. Interviews with the CNA and the Director of Nursing (DON) confirmed that hand hygiene was not performed as required during the meal service. The DON acknowledged that infection prevention and control practices were not maintained during the observed lunch service, specifically noting the failure to perform hand hygiene between serving each meal tray.
Significant Medication Error Leads to Resident Harm
Penalty
Summary
The facility failed to protect a resident's right to be free from significant medication errors, resulting in actual harm. A resident admitted for respite care with multiple diagnoses, including dementia and hospice status, was prescribed Morphine Sulfate to be administered as needed for shortness of breath. However, the medication order was transcribed incorrectly by nursing staff, leading to the resident receiving the medication on a scheduled basis instead of as needed. This error resulted in the resident receiving excessive doses of morphine over several days, leading to a semi-comatose state, constricted pupils, weak and irregular pulse, labored respirations, and hypotension. The transcription error occurred when the nursing staff entered the medication order into the electronic medical record (EMR) with the incorrect concentration and frequency. The order was supposed to be for Morphine Sulfate 100 mg per 5 ml, but it was entered as 20 mg per 5 ml, and the administration was scheduled every two hours instead of as needed. The error was not identified by the pharmacist during the medication regimen review, and the facility's process for double-checking medication orders failed to catch the mistake. The resident's daughter and sitter noticed changes in the resident's behavior and level of consciousness, prompting a hospice nurse to visit and identify the error. Interviews with facility staff revealed a lack of communication and verification processes. The LPN responsible for verifying the medication order assumed a supervisor would address the discrepancy but did not follow up. The facility's Director of Nursing confirmed the error and acknowledged that the facility's process for transcribing and verifying medication orders was not followed correctly. The hospice medical director and facility medical director both expressed concerns about the significant increase in morphine administration and the lack of communication with hospice providers regarding medication questions.
Incomplete Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that resident medical records were complete and accurate for five residents. The deficiencies were identified through a review of facility policies, medical records, and staff interviews. The facility's policy on emptying urinary collection bags required documentation of urine output, which was not recorded for several residents with indwelling urinary catheters. Additionally, the policy on changes in a resident's condition required detailed observations and communication with healthcare providers, which was not consistently followed. Resident #2 had an indwelling urinary catheter, but there was no documentation of urine output or a catheter change in the medical record from 11/21/2024 to 12/5/2024. Similarly, Residents #17, #18, and #19, who also had indwelling urinary catheters, lacked documentation of urine output in their medical records for specified periods. Resident #10 experienced extreme discomfort and requested to be transported to the ER, but the required SBAR communication tool was not completed. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the lack of documentation for urine output and catheter changes, as well as the absence of the SBAR communication tool for Resident #10's transfer to the ER. These omissions indicate a failure to adhere to facility policies and ensure accurate and complete medical records for residents with indwelling urinary catheters.
Medication Administration Error in Hospice Respite Care
Penalty
Summary
The facility failed to administer medications according to physician orders for a resident receiving hospice respite care. The resident, who had multiple diagnoses including Normal Pressure Hydrocephalus, COPD, Chronic Kidney Disease, Dementia, and was under hospice care, was prescribed Morphine Concentrate 100 mg per 5 ml to be given 0.25 ml or 5 mg every 2 hours as needed for shortness of breath. However, the order was incorrectly transcribed by an LPN as Morphine Sulfate 20 mg per 5 ml, with a dosage of 0.25 ml or 1 mg to be administered every 2 hours routinely, rather than as needed. The error in transcription led to the resident receiving the correct concentration of Morphine Sulfate but at an incorrect frequency, as it was administered routinely instead of on a PRN basis as prescribed. The Director of Nursing confirmed the transcription error and the incorrect administration schedule, acknowledging that the resident received the medication every 2 hours routinely over several days, contrary to the physician's order.
Pharmacist Fails to Identify Transcription Error in Hospice Resident's Medication Order
Penalty
Summary
The facility failed to ensure that a licensed pharmacist accurately identified and corrected a transcription error in the medication administration record (MAR) for a hospice respite resident. The error involved the incorrect transcription of a physician's order for Morphine Concentrate, which was intended to be administered as needed (PRN) for shortness of breath. Instead, the order was transcribed with the wrong concentration and as a scheduled order, leading to the administration of incorrect doses. The resident involved was admitted for respite care with multiple diagnoses, including Normal Pressure Hydrocephalus, COPD, Chronic Kidney Disease, Dementia, and was under hospice care. The hospice physician's order specified Morphine Concentrate 100 mg per 5 ml, to be given 0.25 ml or 5 mg every 2 hours as needed. However, the MAR incorrectly documented the concentration as 20 mg per 5 ml, resulting in a 1 mg dose being administered instead of the intended 5 mg dose. This transcription error was not identified by the pharmacist during the Medication Regimen Review (MRR). Interviews revealed that the Director of Nursing acknowledged the transcription error made by a Licensed Practical Nurse, and the pharmacist admitted to missing the error during the MRR. The pharmacist explained that the process for hospice patients involves the pharmacy entering orders into a profile, which is then used by contracting pharmacists for the MRR. Despite receiving the correct concentration from the facility, the pharmacist did not catch the error in the MAR, as the facility's process did not include rechecking the MAR after receiving a signed prescription from the provider.
Medication Transcription Error Due to Inadequate QAPI Program
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to ensure an effective program to identify and address quality deficiencies, specifically related to medication errors. The committee did not perform a root cause analysis or implement corrective systems to ensure appropriate care and safety in the transcription of medication orders. This failure was highlighted by a significant medication error involving a resident's Morphine orders, which were incorrectly transcribed and administered on a scheduled basis rather than as needed (PRN). The resident involved was admitted for respite care with hospice orders for Morphine Concentrate to be given as needed for shortness of breath. However, the orders were incorrectly transcribed by an LPN, resulting in the resident receiving multiple doses of Morphine on a scheduled basis over several days. This error was only identified when the resident's daughter noticed her mother was unusually drowsy and brought it to the attention of the facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON). Despite identifying the error, the facility failed to conduct a thorough investigation or root cause analysis. The QAPI committee did not implement an effective action plan to correct the deficiencies, as they did not include all relevant staff in the education and corrective processes. The facility also failed to ensure clear communication and coordination with hospice and agency staff, which contributed to the transcription errors. The lack of documented audits and comprehensive staff education further exemplified the facility's inadequate response to the medication error.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide written information to residents and/or their representatives regarding the right to formulate an advance directive. This deficiency was identified through a review of facility documents, medical records, and interviews. Specifically, 22 out of 35 residents reviewed did not receive the necessary information about advance directives, which is a critical component of respecting residents' rights to make informed decisions about their care. The medical records of several residents, including those with severe cognitive impairments and those who were cognitively intact, lacked documentation of written information about advance directives. For instance, Resident #103, who had severe cognitive impairment, and Resident #34, who was cognitively intact, both did not have records indicating they were informed about their rights to formulate an advance directive. This pattern was consistent across multiple residents with varying cognitive abilities and medical conditions, such as hypertension, anxiety disorders, and chronic obstructive pulmonary disease. Interviews with facility staff, including the Nurse Liaison and the Social Worker, confirmed that the facility did not provide the required written information to residents or their representatives. The Nurse Liaison, responsible for completing admission paperwork, acknowledged the omission, and the Social Worker corroborated this failure. The Director of Nursing also confirmed the lack of provision of written information, highlighting a systemic issue in the facility's admission process and communication with residents and their families.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their health status. For one resident, the quarterly MDS assessment inaccurately recorded a diagnosis of Pneumonia, which was not documented in the resident's medical record. This resident had a history of severe cognitive impairment and multiple health conditions, including muscle weakness, stroke, and chronic respiratory issues. The MDS Coordinator confirmed the inaccuracy during an interview, acknowledging that the resident did not have a diagnosis of Pneumonia. For another resident, the facility failed to assess and document the resident's oral health status accurately. Despite nurse's notes indicating the resident had natural lower teeth and no upper teeth, the admission and annual MDS assessments reported no dental issues. Furthermore, there was no documentation of the resident being asked about or seen by a dentist since admission. The Director of Nursing and the MDS Coordinator both confirmed the lack of assessment and documentation regarding the resident's oral condition.
Failure to Resubmit PASRR After New Diagnosis
Penalty
Summary
The facility failed to resubmit a Pre-Admission Screening and Resident Review (PASRR) for a resident after a new mental health diagnosis was identified. The resident, who was admitted with diagnoses including Dementia, Anxiety, Panic Disorder, and Adult Failure to Thrive, was found to have severe cognitive impairment and a new diagnosis of Psychosis. Despite this new diagnosis being recorded on 6/12/2020, the facility did not resubmit the PASRR to the state-designated authority as required. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that a new PASRR should have been submitted following the addition of the Psychosis diagnosis.
Failure to Update Care Plans After Falls
Penalty
Summary
The facility failed to revise comprehensive care plans with new interventions after falls for two residents. Resident #37, who has severe cognitive impairment and a history of falls, experienced an unwitnessed fall. Despite the fall being documented in a Falls Investigation Report and the resident being assessed with no injuries, the care plan was not updated with new interventions. The MDS Coordinator acknowledged that it was her responsibility to update the care plan but confirmed that no new interventions were added after the fall. Similarly, Resident #306, with moderate cognitive impairment and a history of falls, fell from a wheelchair. Although anti roll backs were applied to the wheelchair as an immediate intervention and were observed in place during subsequent observations, the comprehensive care plan was not updated to include this intervention. The Director of Nursing confirmed that the care plan should have been revised to reflect the new fall prevention intervention but was not.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate personal grooming for a resident who was unable to perform activities of daily living independently. The facility's policy on Activities of Daily Living (ADL) requires that residents receive appropriate care and services to maintain or improve their ability to carry out ADLs, including grooming and personal hygiene. Despite this policy, Resident #79, who was cognitively intact but dependent on staff for toileting, bathing, and required assistance with personal hygiene, was observed multiple times with long fingernails and brown debris under the nails. There was no documentation indicating that the resident had refused nail care. Observations over several days revealed that the resident's fingernails remained untrimmed and dirty, despite the resident expressing a desire to have them trimmed. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN), confirmed the presence of brown debris under the resident's fingernails. The Director of Nursing stated that she expected nail care to be provided as part of daily care, especially when nails were long or dirty, indicating a failure to adhere to the facility's grooming policy for this resident.
Failure to Secure Chemicals and Medications for Residents
Penalty
Summary
The facility failed to ensure that chemicals and medications were secured for two residents, leading to deficiencies in safety and supervision. Resident #25, who was cognitively intact with a BIMS score of 14, had an unsecured bottle of nail polish remover and an aerosol can of Glade air freshener on her bedside dresser. Despite the resident's awareness of the need to secure these items and the absence of wandering residents in the hallway, the facility's policy required that such chemicals be stored securely. Interviews with staff, including an LPN and the DON, confirmed that these items should not have been left unsecured in the resident's room. Similarly, Resident #27, also cognitively intact with a BIMS score of 15, had an unsecured 200-count bottle of multivitamins on the sink counter in her room. The resident had not been assessed for self-administration of medications, as required by the facility's policy. Observations and interviews with staff, including an LPN and an RN, confirmed that the multivitamin bottle should not have been left unsecured and should have been taken to the nurses' station. The DON reiterated that medications are not supposed to be left unsecured in a resident's room.
Failure to Document Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to document the fluid restriction amount and the amount consumed by a resident requiring dialysis care on the Medication Administration Record (MAR). The facility's policy, revised on May 10, 2023, mandates that the fluid restriction amount and the amount consumed should be documented in the physician's order and on the MAR. However, for Resident #31, who was admitted with diagnoses including Edema, Acute Kidney Failure, and End Stage Renal Disease requiring dialysis, this documentation was not completed. The physician's orders indicated a fluid restriction of 960 ml per day, but the MAR from May 1 to May 31, 2024, lacked any record of the fluid restriction amount or the fluid consumed by the resident each shift. Interviews with staff and the resident confirmed the oversight. A Licensed Practical Nurse (LPN) acknowledged that the fluid consumed by the resident was not documented on the MAR, despite the resident being on a 960 ml/day fluid restriction. A Certified Nursing Assistant (CNA) and the resident herself confirmed that the resident did not have a water pitcher at her bedside, and fluids were provided by dietary and nursing staff. The Director of Nursing (DON) also confirmed the failure to document the fluid restriction and consumption on the MAR, highlighting a lapse in adherence to the facility's policy.
Failure to Develop Dementia Care Plans for Residents
Penalty
Summary
The facility failed to develop a dementia care plan for two residents diagnosed with dementia, as required by their policy. Resident #12 was admitted with diagnoses including Dementia with Psychotic Disturbance, Alzheimer's Disease, and Vascular Disorder of the Intestine. A quarterly Minimum Data Set (MDS) assessment indicated severe cognitive impairment, yet the comprehensive care plan did not address dementia. The Director of Nursing (DON) and the MDS Coordinator confirmed the absence of a dementia care plan, despite the expectation that residents with dementia should have person-centered interventions. Similarly, Resident #21, admitted with Chronic Obstructive Pulmonary Disease, Delusional Disorder, and Severe Vascular Dementia, also lacked a dementia care plan. The quarterly MDS assessment showed severe cognitive impairment, but the care plan did not reflect this diagnosis. Both the DON and the MDS Coordinator acknowledged the oversight, confirming that dementia should have been included in the care plan as per the facility's policy.
Deficiency in PRN Antianxiety Medication Management
Penalty
Summary
The facility failed to provide evaluation and rationale for the continued use of a PRN antianxiety medication for a resident with severe cognitive impairment. The facility's policy on psychotropic medication use, revised in July 2022, states that residents should not receive medications that are not clinically indicated to treat a specific condition and that PRN orders for psychotropic medications are limited to 14 days. However, the medical record review revealed that a resident was prescribed Ativan 0.5 mg every 6 hours as needed for anxiety, initially with a 14-day limit, but subsequently, the order was changed to 0.25 mg without a stop date, and no evaluation or rationale for continued use was documented. Interviews with facility staff, including a Nurse Practitioner and the Director of Nursing, confirmed that the PRN Ativan order for the resident did not have a stop date, and there was no documented evaluation for its continued use. Additionally, the Pharmacist Consultant confirmed that there were no pharmacy recommendations to discontinue the PRN Ativan. This lack of evaluation and documentation for the continued use of the PRN antianxiety medication constitutes a deficiency in the facility's adherence to its policy and regulatory requirements.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as evidenced by several observations and interviews. An insulin pen was found on a medication cart without a pharmacy label, resident name, or open date, and a Licensed Practical Nurse (LPN) was about to use it without knowing when it was opened. Additionally, a medication cart was left unlocked and unattended while an LPN administered medications to a resident, which was confirmed by the LPN. The Director of Nursing (DON) acknowledged that insulin pens should be dated and labeled with resident information when opened. Further deficiencies were noted in the medication room, where the door was propped open and medications, including controlled substances like Hydrocodone and Oxycodone, were left unsecured. Expired medical supplies, such as syringes, needles, IV start kits, and transfer straw kits, were also found in the medication room and available for use. The Pharmacy Director and Pharmacist confirmed that the controlled substances should have been secured behind two locked areas, and the expired supplies should not have been available for use. The DON confirmed the medication cart should not have been left unsecured and acknowledged the presence of expired supplies.
Failure to Arrange Dental Care for a Resident
Penalty
Summary
The facility failed to arrange dental care for a resident, identified as Resident #34, who was admitted with diagnoses including anemia, diabetes mellitus, hypothyroidism, and generalized muscle weakness. The facility's policy on dental services, revised in December 2016, states that routine and 24-hour dental services are provided through various referral options. However, a review of Resident #34's medical records revealed no assessment of the resident's mouth by a nurse or dentist since admission. Observations and interviews conducted on May 28, 2024, noted that the resident had missing and discolored teeth and expressed a desire to see a dentist, yet had not been asked if they wanted dental care. The Director of Nursing confirmed the absence of documentation indicating that the resident had seen a dentist since admission.
Improper Garbage Containment
Penalty
Summary
The facility failed to ensure proper containment of garbage and refuse in one of its six dumpsters. According to the facility's policy on trash disposal, dated August 23, 2023, trash should be disposed of appropriately, and the dumpster area should be maintained for cleanliness and prevention of rodents, with a securely placed dumpster plug. On May 28, 2024, at 11:20 AM, an observation of the outside dumpster area revealed that dumpster #6 was missing a dumpster plug. This observation was confirmed during an interview with the Certified Dietary Manager at 11:25 AM on the same day.
Failure to Obtain Informed Consent for Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer informed consent prior to administering the Pneumococcal vaccine to two residents, which was identified during a review of facility policies, medical records, and staff interviews. The facility's policy, revised on February 7, 2023, mandates that residents should be given the Pneumococcal Immunization upon admission unless medically contraindicated or refused, with documented evidence of acceptance or declination kept on file. Resident #21, admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure, and a history of Pulmonary Embolism, did not have documented informed consent for the vaccination. Similarly, Resident #38, admitted with diagnoses such as Intestinal Obstruction, Chronic Bronchitis, Shingles, and Polyosteoarthritis, also lacked informed consent documentation. The Infection Preventionist confirmed the absence of informed consent for these residents, which was against the facility's expectations.
Transcription Error in Physician's Order for Insulin
Penalty
Summary
The facility failed to accurately transcribe a physician's order for a resident with multiple serious health conditions, including End Stage Renal Disease, Type 1 Diabetes, and Congestive Heart Failure. The resident was prescribed Humulin R (short-acting insulin) to be administered according to a sliding scale protocol. However, the handwritten physician orders were incorrectly transcribed onto the Medication Administration Record (MAR) as Humulin N (intermediate-acting insulin). This transcription error occurred on 12/13/2023 and was not detected until 12/21/2023 when the resident's endocrinologist inquired about the accuracy of the MAR. The error was due to a nurse inadvertently selecting the wrong insulin name from an automated drop-down menu in the facility's electronic record system. Despite the error, the resident continued to receive the correct medication, Humulin R, as the incorrect order had not been sent to the pharmacy for fulfillment, and Humulin N was not available for use. The Director of Nursing (DON) confirmed that the facility launched an investigation upon receiving the endocrinologist's call. The investigation revealed that multiple nursing staff had administered Humulin R per the sliding scale protocol to the resident between 12/13/2023 and 12/21/2023 without detecting the transcription error. The DON acknowledged that the facility had failed to accurately transcribe the new orders onto the MAR, leading to confusion at the endocrinologist's office. The facility's failure to detect the transcription error at the time it was written resulted in a discrepancy between the prescribed medication and the medication listed on the MAR, although the resident did not receive the incorrect insulin due to the pharmacy not fulfilling the erroneous order.
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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