Life Care Center Of Blount County
Inspection history, citations, penalties and survey trends for this long-term care facility in Louisville, Tennessee.
- Location
- 1965 Stewart Lane, Louisville, Tennessee 37777
- CMS Provider Number
- 445520
- Inspections on file
- 18
- Latest survey
- December 6, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Life Care Center Of Blount County during CMS and state inspections, most recent first.
The facility failed to implement Enhanced Barrier Precautions (EBP) for 14 residents with medical conditions requiring such precautions, such as indwelling urinary catheters and PICC lines. Observations showed no EBP signage or PPE in residents' rooms, and staff were unaware of EBP requirements. Additionally, a resident self-administered medications without a care plan, as confirmed by the ADON.
The facility did not comply with its policy to record refrigerator and freezer temperatures twice daily, affecting three refrigerators and two freezers. Temperature logs for November 2024 showed missing entries for several dates, and the Certified Dietary Manager confirmed the logs were incomplete, potentially impacting 88 residents.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or wounds, as required by their policy. Observations revealed a lack of EBP signage and PPE in residents' rooms, and staff interviews indicated a lack of awareness about EBP requirements. The Director of Nursing confirmed the oversight, which affected residents with conditions like chronic kidney disease and infections.
A resident with Clostridium Difficile (C-diff) was placed in isolation upon admission, but the facility failed to document this on the MDS assessment. Despite the presence of contact precautions and PPE, the MDS did not reflect the resident's isolation status, as confirmed by staff and the resident. This oversight was acknowledged by the MDS RN during a record review.
A resident was found to have unsecured medications in their room, which they self-administered without an assessment or care plan for self-medication storage and administration. The resident, who was cognitively intact, had several medications, some partially used, indicating self-administration. The ADON confirmed the lack of assessment for medication storage and self-administration, leading to a deficiency in the facility's medication management.
A resident with dementia entered another resident's room, disrobed, and attempted to remove her brief, causing her distress and anxiety. The incident was observed by a hospitality aide who intervened immediately. The affected resident, who has dementia and anxiety, was found to be upset and tearful, leading to an increase in her antidepressant medication and administration of an antianxiety medication. The facility's failure to protect her from abuse resulted in actual harm.
The facility failed to accurately post daily nurse staffing information and maintain records for 18 months. Discrepancies were found between posted and actual staff present, with no designated person to update changes. The facility used a dry erase board for postings and did not keep records, violating policy.
A resident with severe cognitive impairment entered another resident's room, disrobed, and attempted to remove the resident's brief. Staff intervened, but the incident was not reported to the State Agency as required by facility policy. Both residents were placed on one-to-one supervision, and the resident responsible was transferred for evaluation. The Executive Director acknowledged the failure to report the incident, which constitutes a deficiency in compliance with federal regulations.
A facility failed to accurately complete a discharge MDS assessment for a resident at risk for falls. The resident, admitted with a fracture, muscle weakness, and lack of coordination, was found on the floor next to their bed. Despite this, the discharge MDS inaccurately reported no falls since admission. The MDS Coordinator RN and LPN confirmed the fall was not captured, resulting in an inaccurate assessment.
The facility failed to provide scheduled showers for three dependent residents, leading to a deficiency in care for ADLs. A resident with severe cognitive impairment received only 3 out of 13 scheduled showers in a month, while another resident, cognitively intact but requiring assistance, received fewer showers than scheduled over several months. When showers were missed, bed baths or sponge baths were provided. The DON confirmed the expectation of three showers per week, but records showed this was not consistently met.
Failure to Implement Enhanced Barrier Precautions and Medication Self-Administration Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for Enhanced Barrier Precautions (EBP) for 14 residents who required such precautions due to various medical conditions, including the presence of indwelling urinary catheters, PICC lines, and pressure ulcers. Observations revealed that there was no EBP signage posted or Personal Protective Equipment (PPE) available in or outside the rooms of these residents. Interviews with staff, including the Interim Unit Manager and Certified Nursing Assistants, indicated a lack of awareness regarding the need for EBP for these residents. Resident #12, for example, was admitted with diagnoses including Hemiplegia and an indwelling urinary catheter, yet the care plan was not developed or implemented for EBP. Similarly, Resident #18, who also had an indwelling urinary catheter, did not have EBP implemented despite physician orders indicating the need for such precautions. Observations confirmed the absence of EBP signage and PPE for these residents, and staff interviews revealed a lack of awareness about the EBP requirements. Additionally, the facility failed to develop a comprehensive care plan for the self-administration of medications for Resident #235. This resident was observed to have several medications in their room, which they self-administered without a care plan in place to assess or guide this practice. The Assistant Director of Nursing confirmed that the resident was not care planned for medication self-administration, highlighting a gap in the facility's care planning process.
Failure to Document Refrigerator and Freezer Temperatures
Penalty
Summary
The facility failed to adhere to its policy regarding the monitoring and documentation of refrigerator and freezer temperatures in the kitchen. According to the facility's policy titled 'Food Safety,' temperatures for cold food storage should be recorded at least twice daily on the Refrigerator/Freezer Temperature Log. However, a review of the temperature logs for the month of November 2024 revealed that temperatures were not obtained or documented for the evening or PM shifts on several dates, specifically 11/17, 11/23, and 11/25. Additionally, on 11/30, temperatures were not recorded for either the morning or AM shift. This lapse in documentation affected three refrigerators and two freezers in the kitchen. During an interview, the Certified Dietary Manager (CDM) confirmed that it was her expectation for the temperature logs to be completed daily for each shift, both AM and PM. The CDM acknowledged that the kitchen's refrigerator and freezer temperatures were not obtained twice daily, resulting in incomplete temperature logs that did not comply with the facility's policy. This failure had the potential to affect 88 of the 93 residents in the facility, as it could lead to improper food storage conditions.
Failure to Implement Enhanced Barrier Precautions for Residents
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for 14 residents who required them due to the presence of indwelling medical devices or wounds. The facility's policy on EBP, which was reviewed on June 3, 2024, mandates the use of EBP for residents with wounds or indwelling medical devices, even if they are not known to be infected. However, observations and interviews revealed that there was no EBP signage or personal protective equipment (PPE) available in or outside the rooms of these residents. Several residents, including those with indwelling urinary catheters, PICC lines, and feeding tubes, were not placed under EBP as required. For instance, Resident #12 had an indwelling urinary catheter, but there was no EBP signage or PPE available in or outside the resident's room. Interim Unit Manager A was unaware of the need for EBP for this resident until December 2, 2024. Similar deficiencies were observed for other residents, such as Resident #18 and Resident #36, who also had indwelling urinary catheters but lacked the necessary EBP measures. Interviews with staff, including Interim Unit Manager A, Hospitality Aide E, CNA F, and LPN G, revealed a lack of awareness regarding the EBP requirements for residents with specific medical devices. The Director of Nursing confirmed the facility's failure to ensure that residents were placed in EBP until after the survey team arrived. This oversight affected residents with various medical conditions, including chronic kidney disease, diabetes, and infections, who required additional precautions to prevent the spread of infections.
Failure to Document Isolation Precautions on MDS
Penalty
Summary
The facility failed to accurately document the isolation treatment for a resident diagnosed with Clostridium Difficile (C-diff) on the Minimum Data Set (MDS) assessment. The resident, who was admitted with diagnoses including C-diff, Chronic Obstructive Pulmonary Disease (COPD), and Rheumatoid Arthritis, was placed into isolation precautions upon admission due to the active C-diff infection. Despite the implementation of contact precautions, the MDS assessment did not capture the resident's isolation status, which is a requirement according to the MDS 3.0 Resident Assessment Instrument (RAI) Manual. Observations and interviews confirmed that the resident was under isolation precautions, with signage and Personal Protective Equipment (PPE) present outside the resident's room. The Unit Manager LPN and the resident both confirmed the isolation status due to the C-diff infection. However, during a review of the resident's MDS, the MDS Registered Nurse acknowledged that the isolation was not documented on the 5-day MDS assessment, indicating a lapse in accurately coding the resident's treatment and care needs.
Failure to Secure Medications for Resident
Penalty
Summary
The facility failed to secure medications for a resident, leading to a deficiency in medication storage and administration. The resident, who was admitted with diagnoses including muscle weakness, cancer, hearing loss, and cognitive impairment, was not assessed or care planned for self-medication storage and self-administration. Despite being cognitively intact as per the Brief Interview for Mental Status (BIMS) assessment, the resident's comprehensive care plan did not address self-medication. The resident had several medications, including Triamcinolone Acetonide Cream, Lidocaine External Cream, Ophthalmic Solution, and hydrocortisone cream, which were found in the resident's room, some of which were partially used, indicating self-administration. The Assistant Director of Nursing (ADON) confirmed that the medications were available for self-administration and that the resident had not been assessed for medication storage and self-administration. Observations revealed that the resident did not have a roommate, and there were no residents with wandering behaviors on the unit. The facility's policy required an interdisciplinary team assessment to determine if a resident could safely self-administer medications, but this was not completed for the resident in question, leading to the deficiency.
Failure to Protect Resident from Psychosocial Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from psychosocial abuse when another resident entered her room, pulled the covers off her, attempted to remove her brief, and exposed himself. This incident involved Resident #14, who was admitted with diagnoses including Dementia with Anxiety, Depression, and Chronic Kidney Disease, and Resident #15, who had severe cognitive impairment due to Dementia. The event occurred when a hospitality aide observed Resident #15 disrobing and pulling at Resident #14's covers, prompting immediate intervention. Resident #14 was found to be upset and tearful following the incident, as documented in medical records and interviews with healthcare professionals. She was described as anxious and somewhat withdrawn, with her antidepressant medication dosage increased and an antianxiety medication administered following the event. The incident was reported to have caused actual harm to Resident #14, as she exhibited signs of distress and anxiety beyond her baseline condition. Resident #15, who had a care plan indicating a risk for inappropriate behaviors related to dementia, was removed from the room and placed under one-to-one supervision until transferred for a behavioral evaluation. The facility's investigation revealed that staff acted promptly to remove Resident #15 from the situation, but the incident highlighted a failure to protect Resident #14 from abuse, resulting in her experiencing mental anguish.
Inaccurate Staffing Data and Record-Keeping Deficiency
Penalty
Summary
The facility failed to post accurate daily nurse staffing information and maintain records of the staffing data for a minimum of 18 months, as required by their policy. On two of the four days reviewed, discrepancies were noted between the posted staffing data and the actual staff present. For instance, on the night shift of July 9, 2024, the posted data indicated 8.5 Certified Nursing Assistants (CNAs) were scheduled, but only 7.5 CNAs were present due to a call-in and an early departure. The Director of Nursing (DON) confirmed that the staffing data posted in the facility entryway was based on the scheduled plan and was not updated to reflect real-time changes, as there was no designated person responsible for making such updates. Additionally, the facility did not maintain a record of the daily staffing data for the required 18 months. Observations revealed that the staffing data was posted on a dry erase board, and no copies were kept. The DON acknowledged that the posted data was inaccurate and that the facility did not retain records of the staffing data, which is a violation of the facility's policy. This lack of accurate posting and record-keeping was confirmed through interviews and observations conducted during the survey period.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency when a resident exposed himself to another resident. The facility's policy requires that all alleged violations involving abuse be reported immediately, but not later than two hours after the allegation is made. In this case, the incident involved a resident with severe cognitive impairment who entered another resident's room, disrobed, and attempted to remove the resident's brief. The staff intervened and removed the resident from the room, but the incident was not reported to the State Agency as required by the facility's policy. The incident involved Resident #14, who was admitted with diagnoses including Dementia with Anxiety, Depression, Anemia, and Chronic Kidney Disease, and had severe cognitive impairment. The resident was found upset and tearful after the incident, although physically unharmed. Resident #15, who also had severe cognitive impairment, was admitted with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Digestive System and Dementia without Behavioral Disturbance. The resident had not exhibited behaviors prior to this incident. The facility conducted an internal investigation and both residents were placed on one-to-one supervision until Resident #15 was transferred for evaluation. Despite recognizing the potential for abuse, the Executive Director admitted that the incident should have been reported to the State Agency, acknowledging a failure to comply with federal regulations. The facility's inaction in reporting the incident constitutes a deficiency in adhering to mandated reporting requirements.
Inaccurate MDS Assessment for Resident Fall
Penalty
Summary
The facility failed to accurately complete a discharge Minimum Data Set (MDS) assessment for a resident who was reviewed for falls. The review of the Resident Assessment Instrument (RAI) Manual 3.0 and the medical record revealed that the MDS is a critical tool used to assess residents in Medicare or Medicaid certified facilities. It includes various sections that capture clinical data items, such as the number of falls since admission. The medical record indicated that the resident was admitted with diagnoses including a fracture of the right leg, muscle weakness, and lack of coordination, and was identified as being at risk for falls. On a specific date, the resident was found on the floor next to their bed, which was documented in the nurse's notes and the facility's fall investigation. Despite this incident, the discharge MDS assessment inaccurately reported that there were no falls since admission. During an interview, the MDS Coordinator RN and LPN confirmed the fall had occurred and was not captured in the discharge MDS assessment, leading to an inaccurate assessment.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers for three dependent residents, resulting in a deficiency in the care provided for activities of daily living (ADLs). Resident #12, who has severe cognitive impairment and requires assistance from 1-2 staff for bathing, received only 3 out of 13 scheduled showers in September 2023. Similarly, Resident #8, who is cognitively intact but requires moderate assistance with ADLs, received only 3 out of 15 scheduled showers in January 2024, 6 out of 12 in February 2024, and 4 out of 13 in March 2024. Resident #22, who is cognitively intact but dependent on assistance for bathing, received only 2 out of 13 scheduled showers in September 2023 and 1 out of 5 in October 2023. Interviews with staff and residents revealed that when scheduled showers were missed, residents were provided with bed baths or sponge baths instead. The Director of Nursing confirmed that the expectation was for residents to receive three scheduled showers per week, but the records showed that this was not consistently achieved for the residents in question. Despite the lack of documented grievances regarding bathing for Resident #22, the deficiency was identified through a review of ADL documentation and staff interviews.
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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