Life Care Center Of Crossville
Inspection history, citations, penalties and survey trends for this long-term care facility in Crossville, Tennessee.
- Location
- 80 Justice St, Crossville, Tennessee 38555
- CMS Provider Number
- 445167
- Inspections on file
- 20
- Latest survey
- December 4, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Life Care Center Of Crossville during CMS and state inspections, most recent first.
The facility failed to update hospice plans of care for four residents receiving hospice services, as required by their hospice contract and policy. The hospice plans of care were not updated in the medical records or communication binders after the certification periods ended, as confirmed by the Social Services Director and Administrator.
A facility failed to resubmit a PASRR after a resident received new mental health diagnoses, including Unspecified Mood Disorder and Schizoaffective Disorder. Despite policy requirements, the facility did not notify the state mental health authority or submit the necessary documentation for a new evaluation. The Admissions Director did not complete the required Level I screening form within the required timeframe, leading to the cancellation of the PASRR submission by Maximus.
The facility failed to properly contain garbage in two of its three dumpsters, as observed during a survey. Dumpsters A and B were missing drain plugs, leaving openings that exposed the contents to the elements and potential pests. The Certified Dietary Manager confirmed the issue, indicating non-compliance with the facility's waste disposal policy.
The facility did not document assessments for potential contraindications to influenza vaccines in the medical records of four residents with various medical conditions. Although assessments were conducted by the DON and IP, they were not recorded, violating the facility's policy.
The facility failed to offer hand hygiene assistance to three residents before meals, as required by its Infection Prevention and Control Program. Despite policies mandating hand hygiene assistance, staff members did not provide this to residents who were either cognitively impaired or dependent on staff for personal hygiene. Interviews confirmed the omission, and the Director of Nursing acknowledged the expectation for staff to offer hand hygiene assistance prior to meals.
A resident with severe cognitive impairment and an indwelling catheter had their urinary drainage bag left uncovered and visible to the public, violating the facility's dignity policy. An LPN confirmed the absence of a privacy cover, and the DON acknowledged the expectation for all bags to be covered.
A resident with diabetes received expired insulin due to a failure in medication management. The insulin lispro was stored and administered past its expiration date, despite facility policies requiring expiration checks. The resident, who was cognitively intact and had a history of diabetes, received the expired medication without any reported negative outcomes. Interviews with facility staff confirmed the oversight and the potential for reduced medication effectiveness.
The facility failed to maintain kitchen equipment in a sanitary condition and did not discard a dented can, potentially affecting all 78 residents. A dented can of kidney beans was found in the dry storage area, which should have been discarded according to the facility's policy. Additionally, the deep fryer had dried food debris and grease-like residue, indicating it required a deep clean.
A resident with multiple medical conditions, including hemiplegia and functional quadriplegia, fell from bed while receiving incontinence care from two CNAs. The resident, who required two-person assistance for transfers, was not adequately supported and rolled out of bed, resulting in injuries. The facility's investigation found that one CNA did not use proper body mechanics, leading to the fall.
A resident with mild cognitive impairment was struck in the face by another resident with severe cognitive impairment in an LTC facility. The incident occurred when the first resident reached for the call light, leading to a temporary reddened area on his cheek. Despite the facility's policy to prevent abuse, the altercation was not prevented, highlighting a failure in monitoring and protecting residents.
A resident's funds were misappropriated by a facility Hospitality Aide, who used the resident's debit card without permission to make unauthorized purchases. The resident, who was cognitively intact and had multiple medical conditions, reported the incident to the Assistant Business Office Manager. An investigation was conducted, leading to the suspension and eventual termination of the Hospitality Aide for violating the facility's code of conduct. The resident's bank reimbursed the stolen amount.
Failure to Update Hospice Plans of Care
Penalty
Summary
The facility failed to ensure a coordinated plan of care with the hospice provider was available in the medical records for four residents who were receiving hospice services. The facility's hospice contract and policy required that the hospice plan of care be included in the resident's written plan of care and updated regularly. However, upon review, it was found that the hospice plans of care for Residents #6, #19, #21, and #44 were not updated in the medical records or the hospice communication binders located at the nurses' stations. Resident #6, diagnosed with Parkinson's Disease, Diabetes Mellitus, and Heart Failure, had a hospice plan of care that was not updated after the certification period ended on 9/16/2024. Resident #19, with Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and Depression, also lacked an updated hospice plan of care after 12/14/2023. Similarly, Resident #21, with Respiratory Failure, Heart Failure, and Dementia, and Resident #44, with Parkinson's Disease, Depression, and Dementia, did not have updated hospice plans of care after their respective certification periods ended. Interviews with the Social Services Director and the Administrator confirmed the lack of updated hospice plans of care for these residents.
Failure to Resubmit PASRR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to resubmit a Pre-Admission Screening and Resident Review (PASRR) in a timely manner after a new mental health diagnosis was made for a resident. The facility's policy requires coordination with the PASRR program and mandates a referral for a Level II resident review upon a significant change in a resident's mental health status. Despite this, the facility did not promptly notify the state mental health authority or submit the necessary documentation for a new PASRR evaluation after the resident received new diagnoses of Unspecified Mood Disorder, Unspecified Psychosis, and Schizoaffective Disorder. The resident in question had a history of mental health issues, including Major Depressive Disorder, Generalized Anxiety, and Dementia. Over time, the resident received additional diagnoses, which should have triggered a new PASRR submission. However, the facility's Admissions Director did not complete the required Level I screening form or submit the requested information within the required timeframe, leading to the cancellation of the PASRR submission by Maximus, the organization responsible for processing these reviews. Interviews with the facility's Admissions Director and a Maximus Help Desk Representative revealed a misunderstanding regarding the necessity of resubmitting a PASRR for residents with new psychiatric diagnoses, even if they had previously been excluded due to a primary diagnosis of dementia. The facility's failure to comply with the PASRR requirements resulted in a deficiency, as the necessary evaluations and notifications were not conducted in accordance with state regulations.
Improper Containment of Garbage in Dumpsters
Penalty
Summary
The facility failed to ensure that garbage and refuse were properly contained in two of the three dumpsters, specifically dumpsters A and B. According to the facility's policy on the disposal of garbage and refuse, all waste should be properly contained and covered, and areas where garbage is located should be kept clean. However, during an observation of the outside dumpster area, it was noted that dumpsters A and B were missing drain plugs, leaving a golf-ball sized opening at the bottom corner of each dumpster. This deficiency resulted in the dumpsters' contents being exposed to the elements and potential pests. The Certified Dietary Manager (CDM) confirmed during an interview that the drain plugs for dumpsters A and B were not intact, leading to improper containment of the dumpsters' contents. This observation and confirmation highlight the facility's failure to adhere to its own policy regarding waste disposal, thereby compromising the proper containment of garbage and refuse.
Failure to Document Contraindication Assessments for Influenza Vaccines
Penalty
Summary
The facility failed to document assessments for potential contraindications to influenza vaccines in the medical records of four residents. These residents, who had various medical conditions such as Alzheimer's Disease, Diabetes, Dementia, Chronic Obstructive Pulmonary Disease, Functional Quadriplegia, Congestive Heart Failure, Chronic Kidney Disease, and Dysphagia, consented to and received the influenza vaccine. However, their medical records lacked documentation of assessments for contraindications, which is required by the facility's policy. Interviews with the Director of Nursing (DON) and the Infection Preventionist (IP) revealed that while residents were assessed for contraindications at the time of vaccine administration, these assessments were not documented in the medical records. The DON and IP confirmed that assessments included checking for allergies, past reactions to vaccines, and other contraindications such as Guillain-Barre syndrome and acute illnesses. Despite these assessments being conducted, the lack of documentation in the medical records constituted a deficiency according to the facility's policy.
Failure to Provide Hand Hygiene Assistance Before Meals
Penalty
Summary
The facility failed to offer hand hygiene assistance to three residents prior to meals, as observed during meal tray distribution on two of four hallways. The facility's Infection Prevention and Control Program (IPCP) policy, revised on June 13, 2024, mandates that residents should be advised of hand hygiene standards before eating. Additionally, the facility's policy on feeding residents requires staff to assist residents with hand hygiene prior to meals. However, during observations, staff members did not offer hand hygiene assistance to Residents #8, #23, and #16 before delivering their lunch trays. Resident #8, who is cognitively intact but requires setup or clean-up assistance for eating and is dependent on staff for personal hygiene, did not receive hand hygiene assistance from LPN B. Similarly, Resident #23, who is severely cognitively impaired and dependent on staff for eating and personal hygiene, was not offered hand hygiene assistance by LPN C. Resident #16, who is cognitively intact but requires setup or clean-up assistance for eating and is dependent on staff for personal hygiene, also did not receive hand hygiene assistance from CNA D. Interviews with the staff confirmed the omission of hand hygiene assistance, and the Director of Nursing acknowledged that staff were expected to offer such assistance to all residents prior to meals.
Failure to Maintain Resident Dignity by Not Covering Urinary Drainage Bag
Penalty
Summary
The facility failed to uphold the resident's right to dignity by not covering an indwelling catheter drainage bag, leaving it visible to the public. The facility's policy on dignity, dated May 6, 2019, explicitly states that all residents should be treated with dignity and respect, which includes covering urinary catheter bags to prevent demeaning practices. However, during an observation on December 2, 2024, it was noted that a resident's urinary drainage bag was left uncovered and visible from the hallway, violating this policy. The resident involved was admitted with a diagnosis related to a disorder of the kidney and ureter and had an indwelling catheter due to obstruction. The resident's medical records indicated severe cognitive impairment, as evidenced by a score of 0 on the Brief Interview for Mental Status (BIMS) assessment. During an interview, an LPN confirmed the absence of a privacy dignity cover on the resident's urinary drainage bag, and the Director of Nursing acknowledged that all such bags were expected to be covered, confirming the deficiency in maintaining the resident's dignity.
Expired Insulin Administered to Resident
Penalty
Summary
The facility failed to ensure that an expired medication was not available for resident use, specifically affecting one resident who was receiving insulin. During an observation, it was found that insulin lispro, an injectable medication used to lower blood sugar levels, was stored in a medication cart past its expiration date. The insulin was labeled as opened and expired, yet it was still administered to the resident. The Licensed Practical Nurse (LPN) confirmed that the expired insulin was the only cartridge available and had been used for the resident's medication administration. The resident involved had a medical history including diabetes, morbid obesity, and heart failure, and was cognitively intact according to a recent assessment. The resident's care plan included monitoring blood sugar levels and administering medications as ordered. Despite the expired insulin being administered for several days, blood sugar checks did not reveal any negative outcomes. Interviews with the Director of Nursing and the Pharmacist confirmed that the insulin should have been discarded after 28 days, and using it past the expiration date could reduce its effectiveness, although no harm was reported in this case.
Sanitation and Equipment Maintenance Deficiency
Penalty
Summary
The facility failed to maintain kitchen equipment in a sanitary condition and did not discard a dented can, potentially affecting all 78 residents. The facility's policy on sanitation and maintenance, dated April 26, 2023, requires cleaning fixed equipment with detergent and hot water, rinsing, air-drying, and spraying with a sanitizing solution. During an observation and interview on December 2, 2024, with the Certified Dietary Manager (CDM), a 6.88-pound can of dark red kidney beans was found dented on one side in the dry storage area, which was available for resident use. The CDM acknowledged that the kitchen staff checks for dented cans weekly and confirmed that the dented can should have been discarded but was missed during the check. Additionally, during an observation of the cooking area, the deep fryer was found to have dried brownish-yellow food debris with a grease-like residue on the right side. The CDM stated that the deep fryer was last used on November 30, 2024, and was cleaned after use. However, the CDM confirmed that the deep fryer required a deep clean to remove all the grease-like, brownish-yellow food debris present.
Resident Fall Due to Inadequate Support During Care
Penalty
Summary
The facility failed to prevent a fall for a resident, resulting in actual harm. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, diabetes, and functional quadriplegia, was dependent on staff for various activities of daily living, including toileting and transfers. During an incident, the resident was being provided incontinence care by two CNAs when she was rolled onto her side and subsequently fell from the bed to the floor, sustaining injuries. The resident was cognitively intact and required two staff members for assistance with transfers, as documented in her comprehensive care plan. On the day of the incident, while being repositioned in bed by two CNAs, the resident was not adequately supported and rolled out of bed, landing face down on the floor. This resulted in complaints of pain in the neck, head, right arm, shoulder, and index finger, along with visible bruising on the forehead. The facility's investigation revealed that one of the CNAs involved in the incident did not provide proper body mechanics to ensure the resident's safety during the care process. The resident reported that the CNA let her fall, and the facility confirmed that the CNA's actions did not meet the safety needs of the resident during activities of daily living care.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident struck him in the face. Resident #9, who had mild cognitive impairment and required assistance for daily activities, was involved in an altercation with Resident #2, who had severe cognitive impairment and a history of aggressive behavior. The incident occurred when Resident #9 reached for the call light, and Resident #2 struck him in the face, resulting in a temporary reddened area on Resident #9's cheek. The facility's investigation revealed that the incident was reported by Resident #9 to a CNA, and an LPN assessed the situation, confirming the physical contact. Interviews conducted by the LPN indicated that both residents were seated in their wheelchairs when the altercation occurred. Despite the facility's policy to prevent and prohibit all types of abuse, the incident was not prevented, and the residents were not adequately monitored to prevent such occurrences.
Misappropriation of Resident's Funds by Facility Staff
Penalty
Summary
The facility failed to protect a resident's rights to be free from misappropriation and/or exploitation when money totaling $119.49 was taken from a resident. The facility's policy on abuse, neglect, and exploitation, revised on 7/18/2023, defines misappropriation as the deliberate misplacement or use of a resident's property or money without consent. The resident involved was admitted with multiple diagnoses, including Metabolic Encephalopathy, Type 2 Diabetes Mellitus, Morbid Obesity, Acute and Chronic Respiratory Failure, Anxiety, and Quadriplegia. The resident was cognitively intact, as indicated by a score of 15 on the Brief Interview for Mental Status (BIMS) assessment. The incident came to light when the resident informed the Assistant Business Office Manager (ABOM) that her debit card was used without her permission to purchase food at a local restaurant. The ABOM advised the resident to dispute the charges with her bank, which required a police report. The facility initiated an investigation, during which a Hospitality Aide was identified as a suspect and subsequently suspended. The facility substantiated the abuse and terminated the Hospitality Aide for violating the code of conduct. The resident's bank reimbursed her for the disputed amount of $119.49.
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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