Life Care Center Of Greeneville
Inspection history, citations, penalties and survey trends for this long-term care facility in Greeneville, Tennessee.
- Location
- 725 Crum Street, Greeneville, Tennessee 37743
- CMS Provider Number
- 445228
- Inspections on file
- 17
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Life Care Center Of Greeneville during CMS and state inspections, most recent first.
Surveyors observed multiple sanitation failures in the kitchen, including soiled equipment such as the ice machine, dish machine, stove, microwave, oven, and can opener, as well as damaged plate warmer seals and heavily soiled floors. Food storage issues included an inoperable refrigerator thermometer, a freezer with excessive ice build-up, open and undated frozen food, and expired thickened cranberry juice available for use. The Certified Dietary Manager confirmed these deficiencies and acknowledged the kitchen was not maintained in a clean and sanitary condition.
A resident with severe cognitive impairment was readmitted with a PICC line for IV antibiotics following bacteremia and UTI, but the care plan was not updated to include the new vascular access device as required. Despite physician orders and ongoing observations confirming the presence of the PICC line, the care plan only addressed ADL deficits and infection risk, omitting the PICC line and related care needs.
A resident with physical limitations and no order to self-administer medications was found with antacid tablets left unsecured at the bedside. Facility staff confirmed that medications should not be stored at the bedside and that the resident was not permitted to self-administer, resulting in a deficiency for improper medication storage and supervision.
A resident with a history of heart failure and dependence on supplemental oxygen was observed receiving oxygen at 1.5 LPM instead of the physician-ordered 2 LPM. Despite clear orders and care plan instructions, staff, including an LPN and the Interim DON, confirmed the oxygen was not set at the prescribed rate. The nurse practitioner also acknowledged the requirement to follow the ordered rate.
A resident with multiple chronic conditions was prescribed Vitamin D3, but the pharmacy delivered Vitamin D2 instead. During medication administration, an RN identified the discrepancy, and the interim DON confirmed that the pharmacy had not supplied the correct medication as ordered. The pharmacy consultant acknowledged the error but could not explain why the wrong medication was sent.
A resident with severe cognitive and physical impairments, who required an indwelling urinary catheter, was observed on two occasions with the catheter drainage bag stored directly on the floor beneath the bed. Facility policy and staff interviews confirmed that catheter bags should not be placed on the floor to maintain infection control, but this protocol was not followed.
A facility failed to transmit a discharge MDS assessment within the required timeframe for a resident who was discharged to the hospital. The resident, admitted with conditions such as Pneumonia and Pressure Ulcers, did not have the necessary assessment completed or transmitted, resulting in a delay of over 120 days. The MDS Coordinator confirmed the oversight during an interview.
A resident experienced significant unplanned weight loss, which was inaccurately documented as a physician-prescribed weight-loss regimen in the MDS assessment. The resident's weight decreased from 242 to 178 pounds over 180 days. Interviews with the MDS Coordinator and RD confirmed the error, as the resident was not on a prescribed weight-loss program.
The facility failed to refer two residents for a Level II PASARR after new diagnoses of Psychosis were added. Despite facility policy requiring notification of state authorities for significant changes in mental condition, no referrals were made. Both residents had assessments indicating potential mental health issues, but the necessary screenings were not conducted.
The facility failed to update comprehensive care plans for two residents, leading to deficiencies. A resident with a urinary tract infection and multi-drug resistant organism did not have transmission-based precautions included in their care plan. Another resident with psychosis and hallucinations had a care plan that did not reflect these conditions. The DON confirmed these omissions, highlighting lapses in care planning.
A resident's medical record was found to be incomplete and inaccurate due to a failure to document a urine specimen collection, despite a physician's order for a urinalysis culture and sensitivity. The RN responsible admitted to obtaining the specimen but forgot to document the procedure, which was confirmed by the DON as a deviation from the facility's documentation expectations.
The facility failed to offer hand hygiene to two residents before an evening meal, as observed on one unit. The facility's policy requires maintaining an infection prevention and control program, but staff did not assist the residents with hand hygiene, confirmed by both the staff and residents. The DON acknowledged that infection control practices were not maintained.
A facility failed to allow a resident to return after hospitalization, despite being capable of care, due to family expectations. Another resident was discharged with incorrect medications, which were later returned without adverse effects. Both incidents highlight deficiencies in discharge and medication handling procedures.
Failure to Maintain Sanitary Kitchen and Proper Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by multiple observations of soiled equipment, improper food storage, and expired food items. During a kitchen inspection, surveyors noted the ice machine was visibly soiled with dust and unknown black, brown, and white debris on both the outside and inside rims, including a large amount of black substance in a gap of the door rim. The dish machine and surrounding areas, including the floor and drainage pipe, were found with dried food debris, accumulated grime, and unknown substances. The stove, microwave, oven, and can opener were all observed with significant build-up of grease, dried food particles, and other residues. Additionally, the 3-compartment plate warmer had loose food particles and damaged gasket seals, and the floor behind the oven and stove was heavily soiled with dirt, dead insects, and grime. Further deficiencies included improper food storage and temperature monitoring. The small walk-in refrigerator contained a digital thermometer that was inoperable, with no other thermometers available, despite staff documenting daily temperatures as within acceptable parameters. The reach-in chest type ice cream freezer had a large amount of ice build-up, and one thermometer was covered in ice. In the walk-in freezer, a box of frozen biscuits was found open, undated, and exposed to air. On the dry storage rack, two boxes of thickened cranberry juice were expired but still available for resident use. Facility policy reviews indicated that the Director of Food and Nutrition Services was responsible for ensuring cleanliness and sanitation in accordance with regulatory requirements, including proper cleaning schedules, equipment sanitization, and temperature monitoring. However, the observed conditions in the kitchen and storage areas did not align with these policies. The Certified Dietary Manager confirmed the presence of expired food, soiled equipment, and the inoperable thermometer, acknowledging that the kitchen and its equipment were not maintained in a clean and sanitary condition.
Failure to Update Care Plan for Resident with New PICC Line After Hospital Readmission
Penalty
Summary
The facility failed to revise the comprehensive care plan for one resident following a significant change in condition after hospital readmission. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was readmitted with a vascular access device (PICC line) for IV antibiotic therapy due to bacteremia and a urinary tract infection. Despite physician orders and documentation indicating the presence of the PICC line and the need for ongoing IV antibiotics, the care plan was not updated to reflect the new vascular access device within the required timeframe. Observations conducted several days after readmission confirmed the continued presence of the PICC line in the resident's right upper extremity. Interviews with facility staff, including the Interim DON, confirmed that the care plan should have been updated within seven days of readmission, but this was not done. The care plan only addressed the resident's ADL deficits and infection risk, with no mention of the PICC line or related care needs.
Failure to Secure Medications at Bedside
Penalty
Summary
The facility failed to ensure that medications were stored and secured properly for one resident. According to facility policy, medications are to be administered safely and appropriately, and there was no documentation allowing the resident to self-administer medications. The resident in question had diagnoses including malignant neoplasm of the bladder, muscle weakness, and required assistance with activities of daily living due to physical limitations, including impairment in both upper extremities. The resident was cognitively intact but required staff setup and cleanup assistance with eating and personal hygiene. During observation, three antacid tablets were found in a medicine cup on the resident's over-bed table, accessible to the resident without staff supervision. There was no physician's order permitting the resident to self-administer medications. Both the RN and the Interim DON confirmed that the resident did not have the ability to self-administer medications and that medications should not be stored at the bedside. The facility's failure to properly store the antacid tablets resulted in a deficiency related to accident hazards and inadequate supervision.
Failure to Administer Oxygen at Physician-Ordered Rate
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered at the physician-prescribed rate for a resident who required supplemental oxygen. According to facility policy, oxygen orders must specify the required liter flow, and staff are expected to administer oxygen as ordered. The resident in question had a history of heart failure, heart disease, and dependence on supplemental oxygen, and was assessed as having moderate cognitive impairment. The care plan and physician orders specified oxygen at 2 liters per minute (LPM) via nasal cannula as needed, with instructions to monitor oxygen saturation and notify the physician if levels dropped below 90%. Multiple observations over two days revealed that the resident consistently received oxygen at 1.5 LPM instead of the prescribed 2 LPM. Both the resident and staff, including an LPN and the Interim DON, confirmed that the oxygen was not set at the ordered rate. The nurse practitioner acknowledged that, regardless of perceived risk, oxygen therapy should be administered at the rate ordered by the medical provider. The deficiency was identified through policy review, medical record review, direct observation, and staff interviews.
Incorrect Medication Delivered by Pharmacy
Penalty
Summary
The facility failed to ensure that the pharmacy provided an accurate, physician-prescribed medication for a resident. According to the medical record, the resident was admitted with diagnoses including Alzheimer's Disease, Dementia, Osteoarthritis, and Glaucoma, and had a current physician order for Vitamin D3 oral capsule 1.25 mg to be administered once weekly. During medication administration, a registered nurse retrieved a medication card containing Vitamin D2 instead of the prescribed Vitamin D3. The interim Director of Nursing confirmed that the medication card, dated over a month prior, contained Vitamin D2 and that the pharmacy had not delivered the correct medication as ordered. The pharmacy consultant also confirmed that Vitamin D2 was delivered and was unable to explain why the incorrect medication was sent.
Failure to Maintain Proper Urinary Catheter Bag Storage
Penalty
Summary
The facility failed to follow proper infection control practices regarding the storage of a urinary catheter drainage bag for one resident. Facility policy required that urinary catheter bags not be placed on the floor and that infection prevention and control procedures be followed. Medical record review showed the resident had significant physical and cognitive impairments, required substantial assistance with activities of daily living, and had an indwelling urinary catheter with orders for catheter care every shift. The resident's care plan also specified catheter care and monitoring for kinks in the tubing. During two separate observations, the resident's urinary catheter drainage bag was found stored directly on the floor, partially under the bed. An LPN confirmed the improper storage and acknowledged that the bag should not be on the floor to maintain infection control. The Interim DON also confirmed that staff were expected to keep catheter bags off the floor and that infection prevention and control practices were not maintained in this instance.
Failure to Transmit Discharge MDS Assessment Timely
Penalty
Summary
The facility failed to transmit a discharge Minimum Data Set (MDS) assessment in a timely manner for one resident. According to the Resident Assessment Instrument (RAI) Version 3.0 Manual, discharge assessments must be transmitted no later than 14 calendar days after the MDS completion date. However, the medical record review revealed that a resident, who was admitted with diagnoses including Pneumonia, Adult Failure to Thrive, Malnutrition, and Pressure Ulcers, and discharged to the hospital, did not have a discharge MDS assessment completed or transmitted. This assessment was more than 120 days overdue. During an interview, the MDS Coordinator confirmed the oversight, acknowledging that the discharge assessment had not been completed or transmitted.
Inaccurate MDS Assessment for Resident's Weight Loss
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident, which was identified during a review of the Resident Assessment Instrument (RAI) Manual 3.0, medical records, observations, and interviews. The resident in question was admitted with diagnoses including End Stage Renal Disease, Diabetes Mellitus, and Gastro-Esophageal Reflux Disease. The quarterly MDS assessment inaccurately indicated that the resident was on a physician-prescribed weight-loss regimen, despite the resident experiencing significant unplanned weight loss over 180 days. The resident's weight decreased from 242 pounds to 178 pounds, a total loss of 26.45% in 180 days, which was not part of a prescribed weight-loss program. Interviews with the MDS Coordinator and the Registered Dietitian (RD) confirmed that the entry on the MDS assessment was marked in error, as the resident was not on a physician-prescribed weight-loss program. The RD noted that the resident's weight was currently at a desired range for their height, but the facility aimed to prevent further weight loss. The error in the MDS assessment was acknowledged by both the MDS Coordinator and the RD, highlighting a discrepancy between the resident's actual care plan and the documented assessment.
Failure to Refer Residents for Level II PASARR
Penalty
Summary
The facility failed to refer two residents, identified with possible serious mental disorders, to the state-designated authority for a Level II Pre-Admission Screening and Resident Review (PASARR). According to the facility's policy, revised on October 6, 2022, the facility is required to notify the appropriate state mental health authority when a resident with a mental disorder experiences a significant change in their condition. This ensures that residents receive the necessary care and services in the most appropriate setting. However, the facility did not submit a PASARR Level II screening for two residents after new diagnoses of Psychosis were added to their medical records. Resident #1 was admitted with diagnoses including Anxiety Disorder and Depression, and later had Psychosis added to their diagnoses. A PASARR dated August 23, 2023, indicated no need for a Level II evaluation unless there was an exacerbation of mental illness. Despite a quarterly assessment showing mild cognitive impairment and indicators of hallucinations and delusions, no Level II screening was submitted. Similarly, Resident #74, admitted with Adjustment Disorder, Anxiety, and Depression, had Psychosis added to their diagnoses. A PASARR dated June 23, 2023, also indicated no need for a Level II evaluation unless conditions changed. Despite a quarterly assessment showing potential indicators of hallucinations and an active diagnosis of Psychotic Disorder, no Level II screening was submitted. The Director of Nursing confirmed the oversight during an interview.
Deficiencies in Comprehensive Care Planning for Two Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in care. Resident #68, who was admitted with diagnoses including muscle weakness and a urinary tract infection, had a care plan that did not include necessary transmission-based precautions despite having a multi-drug resistant organism in the urine. Observations confirmed that contact precautions were in place, but the care plan was not updated to reflect this change, as confirmed by the Director of Nursing (DON). Similarly, Resident #74, admitted with diagnoses including psychosis and depression, had a care plan that failed to reflect the resident's psychosis and hallucinations. The resident was cognitively intact and had potential indicators of hallucinations, yet the care plan only addressed obsessive behavior and hypersexuality. The DON confirmed that the care plan was not updated to include the resident's psychosis and hallucinations, indicating a lapse in the facility's care planning process.
Incomplete Medical Record Documentation for a Resident
Penalty
Summary
The facility failed to ensure the medical record was complete and accurate for a resident, identified as Resident #68, who was admitted with diagnoses including muscle weakness, need for assistance with personal care, and a urinary tract infection. The facility's policy on nursing documentation requires that the medical record reflect the resident's condition and the care and services provided, including any changes in condition. However, a review of the nurse's notes for Resident #68 from early April to late April revealed no documentation of a urine specimen being obtained, despite a physician's order for a urinalysis culture and sensitivity due to increased confusion. On April 23, a urine culture and sensitivity report indicated that a specimen was obtained at the facility. During an interview, a registered nurse (RN A) confirmed that she had obtained the urine specimen on that date using a clean catch method and sent it to the lab for processing but admitted she forgot to document the procedure in the medical record. The Director of Nursing (DON) confirmed that it was the facility's expectation for such procedures to be documented and acknowledged that the medical record for Resident #68 was incomplete and inaccurate due to the lack of documentation.
Failure to Provide Hand Hygiene Before Meals
Penalty
Summary
The facility failed to assist or offer hand hygiene to two residents before an evening meal on one of the units observed for meal service. The facility's policy on hand hygiene, revised on June 13, 2023, mandates the establishment and maintenance of an infection prevention and control program to provide a safe, sanitary, and comfortable environment, preventing the development and transmission of communicable diseases and infections. However, during an observation on April 29, 2024, the Activities Director (AD) did not offer hand hygiene to Resident #76 before setting up the evening meal tray. This was confirmed by both the AD and the resident during interviews. Similarly, on the same day, a Certified Nursing Assistant (CNA) did not offer hand hygiene to Resident #10 before setting up the evening meal tray. Resident #10 confirmed this during an interview, stating that sometimes a wet wipe is provided, but not consistently. The CNA also confirmed the omission. The Director of Nursing (DON) stated that it was her expectation for staff to assist residents with hand hygiene before meals, acknowledging that infection control practices were not maintained in these instances.
Improper Resident Discharge and Medication Handling
Penalty
Summary
The facility failed to permit a resident to return after hospitalization and did not follow proper discharge procedures for another resident. Resident #350, who had severe cognitive impairment and multiple diagnoses including Alzheimer's Disease and Chronic Obstructive Pulmonary Disease, was transferred to the hospital for evaluation and treatment. Despite the facility's policy to allow residents to return after hospitalization, the facility refused to accept Resident #350 back, citing the inability to meet the expectations of the resident's daughter. The facility filled the resident's bed and advised the family to find alternative placement, even though the facility was capable of caring for the resident. In another incident, Resident #195, who also had severe cognitive impairment, was discharged home with her son. However, the facility mistakenly sent home medication cards belonging to another resident, Resident #16. The error was discovered by Resident #195's niece, who returned the medications to the facility. The Director of Nursing confirmed that Resident #16 had received her prescribed medications, and there was no adverse outcome for Resident #195. The facility's failure to properly manage the discharge process and medication handling led to this deficiency.
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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