Life Care Center Of Red Bank
Inspection history, citations, penalties and survey trends for this long-term care facility in Chattanooga, Tennessee.
- Location
- 1020 Runyan Dr, Chattanooga, Tennessee 37405
- CMS Provider Number
- 445240
- Inspections on file
- 17
- Latest survey
- July 17, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Life Care Center Of Red Bank during CMS and state inspections, most recent first.
The facility failed to properly store and sanitize food items and equipment, affecting 84 of 85 residents. Observations revealed dirty kitchen equipment and improperly stored, unlabeled food items in the kitchen and nourishment rooms. The CDM and ADON confirmed these issues, acknowledging non-compliance with facility policies.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with invasive devices, such as urinary catheters and feeding tubes. Observations showed a lack of EBP signage and PPE outside resident rooms. Staff interviews revealed a misunderstanding of EBP requirements, believing they were only necessary for active infections. The Regional Director confirmed the facility's non-compliance with EBP guidelines.
A resident's privacy was compromised when a sign indicating hospice care was visibly posted in their room without consent or documentation. The sign, visible to anyone entering, violated the resident's rights to dignity and confidentiality. The DON and LPN confirmed the sign's inappropriate placement, which was not requested by the resident or their representative.
The facility failed to notify the responsible parties of two residents about significant changes in their conditions. A resident with multiple diagnoses tested positive for COVID-19, but their family was not informed. Another resident with Alzheimer's and a history of falls experienced an unwitnessed fall resulting in an abrasion, yet their responsible party was not notified until four days later. The DON confirmed these notification delays.
The facility failed to accurately complete MDS assessments for four residents, leading to discrepancies in hospice care documentation and discharge status. A resident under hospice care was not coded for hospice services in the MDS, while another resident's discharge to home was inaccurately documented as a hospital discharge. Additionally, a resident requiring total meal assistance was incorrectly assessed as needing only setup or clean-up assistance.
The facility failed to resubmit a PASARR for two residents after new mental health diagnoses were identified. One resident was admitted with Depression and later diagnosed with Adjustment Disorder with Anxiety and Delusions, while another was admitted with multiple disorders and later diagnosed with Delusions. The DON confirmed that new PASARRs should have been completed for both residents.
A resident receiving enteral nutrition due to a stroke had their tube feeding bag and tubing reused for three days, contrary to the facility's policy of changing them every 24 hours. The oversight was confirmed by an LPN and acknowledged by the DON, indicating a failure to follow physician orders and professional standards.
The facility failed to store respiratory equipment properly for three residents, leaving nebulizer and CPAP masks exposed on bedside tables instead of in labeled bags as required by policy. Despite this, no respiratory illnesses were reported among the residents involved.
The facility did not maintain the garbage storage area in a sanitary condition, as observed during a survey. Trash, including paper, used exam gloves, and straws, was found on the ground, along with a partially decayed animal carcass behind a dumpster. The CDM confirmed the area was unclean.
A resident with diagnoses including Hemiplegia, Hemiparesis, Lack of Coordination, and Muscle Weakness required total 2-person assistance with transfers. Despite the care plan specifying the use of a sit to stand lift and later a Hoyer lift, the resident experienced multiple falls due to improper transfer techniques. These falls resulted in injuries, including fractures requiring surgical intervention. Interviews with the DON and a CNA confirmed that the facility did not follow the care plan, leading to harm from falls. The failure to use the recommended mechanical lifts during transfers highlighted a significant deficiency in care delivery and staff compliance with established protocols.
A resident with Hemiplegia, Hemiparesis, Lack of Coordination, and Muscle Weakness experienced multiple falls resulting in significant injuries, including a left hip fracture and an impacted humeral neck fracture. The resident required total, 2-person assistance with transfers but fell due to inadequate supervision and improper use of transfer devices. Staff interviews revealed that the resident was resistant to care and demanded specific transfer devices, sometimes refusing transfers if his preferred device was not used. The facility's failure to adhere to the care plan and implement proper transfer protocols led to repeated falls and injuries.
A facility's administration did not provide effective oversight or follow corporate notification protocols for falls with major injuries, resulting in harm to a resident with mobility impairments. The resident, who required total 2-person assistance for transfers, sustained multiple injuries due to improper transfer techniques. Staff inconsistently followed the care plan, and refusals to use specific transfer devices were not consistently documented. The former DON failed to notify corporate teams of these incidents, highlighting a lapse in administrative oversight and adherence to established protocols for resident safety.
The facility failed to maintain an accurate medical record for a resident who was resistant to transfers with the Hoyer lift. Despite multiple staff members being aware of and reporting the resident's refusals, these incidents were not documented in the medical record, resulting in an incomplete and inaccurate record.
Improper Food Storage and Sanitation in Facility
Penalty
Summary
The facility failed to ensure proper storage and sanitation of food items and equipment, which had the potential to affect 84 of 85 residents. During a tour of the kitchen, surveyors observed dried food debris on a stainless steel pan, a stand mixer, and a divided plate, all of which were confirmed by the Certified Dietary Manager (CDM) to be dirty and available for use. Additionally, food storage issues were identified, including unlabeled and undated items such as a bag of red seasoning, a jug of teriyaki sauce, flour tortillas, diced ham, and maraschino cherries. These items were improperly stored in dry storage, reach-in, and walk-in refrigerators, contrary to the facility's policies on sanitation and food safety. Further observations in the nourishment rooms revealed items such as sundae syrup, a can of powdered protein supplement, peanut butter crackers, and cold cereal that were not labeled with resident names or dates, and were available for resident consumption. The CDM and the Assistant Director of Nursing (ADON) confirmed these findings, acknowledging that only resident food should be in the nourishment rooms. The Executive Director also confirmed that the food in the nourishment rooms should be stored according to policy and labeled appropriately, indicating a failure to adhere to the facility's food storage policies.
Failure to Implement Enhanced Barrier Precautions for Residents with Invasive Devices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for eight residents who were reviewed for invasive devices. These residents had various medical conditions requiring indwelling devices such as urinary catheters, feeding tubes, and central venous lines. Despite the facility's policy on EBP, which mandates additional precautions for residents with such devices, there was no signage or personal protective equipment (PPE) available outside the rooms of these residents. Observations revealed that residents with indwelling urinary catheters, such as those with neurogenic bladder or obstructive uropathy, did not have EBP signage posted, nor was PPE available for staff use. Interviews with staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), confirmed a lack of awareness and implementation of EBP. The staff believed that EBP was only necessary if a resident had an active infection, contrary to the facility's policy. The Regional Director of Clinical Services acknowledged the facility's non-compliance with EBP guidelines for residents with invasive devices, despite being aware of updated guidance. This oversight affected residents with various conditions, including those with feeding tubes and dialysis catheters, as no EBP measures were observed or enforced during the survey period.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the confidentiality and privacy of a resident's medical information, violating the resident's rights to dignity and respect. A sign was posted in the room of a resident with Alzheimer's Disease, Dementia, and other medical conditions, indicating that hospice supplies were to be used only for the hospice resident. This sign was visible to anyone entering the room, which compromised the resident's right to personal privacy and confidentiality of medical records as outlined in the facility's policies. The sign was not requested by the resident or their representative, nor was it documented in the resident's care plan. During interviews, both the LPN and the DON confirmed the visibility of the sign and acknowledged that it should not have been posted without a request from the resident or their representative. The DON was unaware of the sign's presence until it was brought to their attention and confirmed that the medical record did not contain any evidence of a request for such signage.
Failure to Notify Resident Representatives of Condition Changes
Penalty
Summary
The facility failed to notify the responsible parties of two residents about significant changes in their conditions, as required by their policies. Resident #14, who has diagnoses including Cerebral Palsy, Dementia, and Diabetes, tested positive for COVID-19. Despite the facility's policy mandating immediate notification of the resident's representative in such cases, there was no documentation that Resident #14's family was informed of the positive COVID status. This was confirmed during an interview with the Director of Nursing (DON) and the resident's responsible party. Similarly, Resident #46, who has Alzheimer's Disease and a history of falls, experienced an unwitnessed fall resulting in an abrasion to the left thigh. Although the facility's policy requires immediate notification of the resident's representative in the event of an accident, the responsible party was not informed until four days after the incident. The DON confirmed the delay in notification, acknowledging that the responsible party should have been notified at the time of the fall.
Inaccurate MDS Assessments for Residents
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Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in the documentation of their care. Resident #1, who was admitted with multiple diagnoses including Quadriplegic Cerebral Palsy and Dementia, was under hospice care since admission. However, the quarterly MDS assessment did not reflect this hospice service, as confirmed by the MDS Coordinator. Similarly, Resident #52, with Alzheimer's Disease and a terminal prognosis, was also receiving hospice care, but the quarterly MDS assessment inaccurately stated that hospice services were not provided. Resident #84, admitted with conditions such as Joint Replacement and Atrial Fibrillation, was planned to be discharged home. Despite this, the discharge MDS assessment inaccurately documented the discharge status as a short-term general hospital, rather than home, as confirmed by the MDS Coordinator. This discrepancy was noted despite the care plan and physician's orders indicating a discharge to home. Resident #45, diagnosed with Parkinson's Disease and requiring total assistance with meals, was inaccurately assessed in the significant change MDS assessment. The assessment indicated the resident required only setup or clean-up assistance with meals, contrary to the physician's order for total assistance. This inaccuracy was confirmed by the Clinical Reimbursement Specialist, highlighting a failure to accurately reflect the resident's needs in the MDS assessment.
Failure to Resubmit PASARR After New Diagnoses
Penalty
Summary
The facility failed to resubmit a Pre-Admission Screening and Resident Review (PASARR) in a timely manner after new mental health diagnoses were identified for two residents. According to the facility's policy, any resident with a newly evident or possible serious mental disorder should be referred for a Level II resident review. However, this procedure was not followed for Resident #11 and Resident #39. Resident #11 was admitted with a diagnosis of Depression, and later received new diagnoses of Adjustment Disorder with Anxiety and Delusions. Despite these new diagnoses, a new PASARR was not submitted, as confirmed by the Director of Nursing (DON). Similarly, Resident #39 was admitted with diagnoses including Anxiety Disorder, Major Depressive Disorder, Primary Insomnia, and Visual Hallucinations. A new diagnosis of Delusions was added later, but the facility did not submit a new PASARR following this change. The DON confirmed that a new PASARR should have been completed after the new diagnosis was added. These oversights indicate a failure to adhere to the facility's policy regarding the coordination of assessments with the PASARR program.
Failure to Change Tube Feeding Bag and Tubing as Required
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Summary
The facility failed to adhere to its policy regarding the timely replacement of tube feeding bags and tubing for a resident receiving enteral nutrition. The policy, revised on 5/28/2024, mandates that feeding bags and tubing be changed every 24 hours in accordance with physician orders and professional standards of practice. Resident #587, who was admitted with conditions including Hemiplegia, Hemiparesis, and a Cognitive Communication Deficit, required nutritional support through a feeding tube due to a stroke. Physician's orders specifically instructed that the PEG syringe and feeding bags be changed every night shift. However, during an observation and interview, it was revealed that the feeding bag dated 7/12/2024 was reused for three days without being replaced, contrary to the 24-hour change requirement. The resident's representative reported witnessing a nurse refilling the old bag instead of replacing it. This was confirmed by LPN D, who acknowledged the oversight. The Director of Nursing (DON) also confirmed that the expectation was for daily changes of the tube feeding bag and tubing, highlighting a lapse in following the established protocol.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to appropriately store respiratory equipment for three residents, leading to a deficiency in providing safe and appropriate respiratory care. The facility's policy requires that respiratory supplies, such as nebulizer and CPAP masks, be stored in a bag labeled with the resident's name when not in use. However, observations revealed that the nebulizer masks for Residents #587 and #588, and the CPAP mask for Resident #589, were left exposed on their bedside tables instead of being stored properly. Resident #587, who has severe cognitive impairment and diagnoses including COPD and obstructive sleep apnea, was observed with a nebulizer mask lying uncovered on the bedside table. Similarly, Resident #588, who is cognitively intact and also diagnosed with COPD, had a nebulizer mask left exposed on the bedside table. Resident #589, with diagnoses of COPD and chronic respiratory failure, had a CPAP mask lying exposed on the bedside table. These observations were confirmed by the Assistant Director of Nursing (ADON) during interviews and walkthroughs. The Director of Nursing (DON) and the ADON both acknowledged that the respiratory equipment should have been stored in bags with the residents' names and dates after use, as per facility policy. Despite the improper storage, a Nurse Practitioner confirmed that none of the residents had experienced respiratory illnesses since admission, indicating that the deficiency had not yet resulted in adverse health effects for the residents.
Unsanitary Conditions in Garbage Storage Area
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Summary
The facility failed to maintain the garbage and refuse storage area in a sanitary condition, as required by their policy titled 'Disposal of Garbage and Refuse.' During an observation, it was noted that the dumpster area, which was surrounded on three sides by a fence, contained trash on the ground, including paper, used exam gloves, and straws. Additionally, a partially decayed animal carcass with exposed bones was found behind one of the dumpsters. The Certified Dietary Manager (CDM) confirmed during an interview that the dumpster area was generally unclean and had not been maintained in a sanitary condition.
Failure to Implement Comprehensive Care Plan Resulting in Resident Harm
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Summary
The facility failed to implement the comprehensive care plan for Resident #3, resulting in actual harm to the resident. Resident #3, admitted with diagnoses including Hemiplegia, Hemiparesis, Lack of Coordination, and Muscle Weakness, required total 2-person assistance with transfers. Despite the care plan indicating the use of a sit to stand lift and later a Hoyer lift for transfers, Resident #3 experienced multiple falls due to improper transfer techniques. These falls led to injuries, including a left femur fracture and a left humeral fracture, requiring surgical intervention and emergency room visits. During interviews with the Director of Nursing and CNA #6, it was confirmed that the facility failed to follow Resident #3's comprehensive care plan related to fall interventions, leading to harm from the falls on 9/26/2022 and 5/1/2023. CNA #6 admitted to not using the recommended mechanical lifts for transfers as outlined in the care plan. The facility's failure to ensure proper transfer techniques and adherence to the care plan resulted in repeated incidents of harm to Resident #3, highlighting a significant deficiency in care delivery and staff compliance with established protocols. The facility's lack of adherence to the comprehensive care plan for Resident #3, specifically regarding the use of mechanical lifts for transfers, directly contributed to the harm experienced by the resident. Despite clear guidelines in the care plan and facility procedures, CNAs failed to utilize the appropriate equipment during transfers, leading to falls and subsequent injuries. The failure to monitor and implement the care plan interventions effectively resulted in repeated incidents of harm to Resident #3, underscoring the critical importance of proper care plan implementation and staff training in ensuring resident safety and well-being.
Falls and Injuries Due to Inadequate Supervision and Improper Transfer Techniques
Penalty
Summary
The report details a series of incidents involving Resident #3 at a nursing home facility, where the resident experienced multiple falls resulting in significant injuries. Resident #3 was admitted to the facility with diagnoses including Hemiplegia, Hemiparesis, Lack of Coordination, and Muscle Weakness. Despite being assessed as requiring total, 2-person assistance with transfers, Resident #3 experienced falls due to inadequate supervision and improper transfer techniques. The facility's policy on Fall Management emphasized the importance of evaluating hazards, implementing interventions, and monitoring their effectiveness to prevent accidents. The first fall occurred when Resident #3 attempted to transfer himself to the toilet without assistance, resulting in a fall from the wheelchair. Subsequent falls involved staff using inappropriate transfer devices, such as a slide board instead of the recommended sit to stand lift. These incidents led to Resident #3 sustaining a left hip fracture and later an impacted humeral neck fracture. Interviews with staff revealed that Resident #3 was resistant to care and would demand the use of specific transfer devices, sometimes refusing transfers if his preferred device was not used. The facility's failure to adhere to the care plan and implement proper transfer protocols, despite Resident #3's specific needs and care requirements, resulted in repeated falls and injuries. Staff members, including CNAs and nurses, acknowledged instances where correct transfer devices were not used, leading to harm to the resident. These events highlight a critical lapse in supervision and adherence to care plans, ultimately resulting in Resident #3 experiencing preventable accidents with major injuries.
Oversight and Protocol Failures in Fall Management
Penalty
Summary
The facility's Administration failed to provide effective oversight and follow the facility's corporate notification protocol for falls with major injury, resulting in actual harm to Resident #3. Resident #3, admitted with diagnoses including Hemiplegia, Hemiparesis, Lack of Coordination, and Muscle Weakness, sustained a left hip fracture on 9/26/2022 due to a fall during a transfer from bed to wheelchair. Despite being care planned for specific transfer devices, Resident #3 experienced repeated fall occurrences and a transfer injury on 5/1/2023, resulting in a left humerus fracture. The facility's policy identified falls resulting in serious injury as Never Events, requiring immediate notification to corporate teams for review and intervention. Documentation revealed that Resident #3 required total 2-person assistance with transfers and was at risk for falls due to impaired mobility and balance issues. However, staff did not consistently follow the care plan, leading to multiple incidents of improper transfers and subsequent injuries. Interviews with nursing staff confirmed that Resident #3 had been resistant to transfers using specific devices, but these refusals were not consistently documented in the medical record. The Regional Director of Clinical Services highlighted the failure of the former Director of Nursing to notify corporate teams of Resident #3's falls with major injuries, indicating a lack of effective administration oversight that could potentially impact all residents in the facility. The facility's policies emphasized the importance of continuous quality improvement, monitoring adverse events, and implementing corrective actions to prevent future incidents. Despite these policies, the facility's Administration did not adhere to the corporate notification protocol for Never Events, leading to inadequate oversight and intervention in response to Resident #3's repeated falls with major injuries. The deficiency spanned from 9/26/2022 to 8/28/2023, highlighting a significant period of non-compliance with established protocols and care plans for resident safety.
Failure to Document Resident's Refusal of Care
Penalty
Summary
The facility failed to maintain an accurate medical record for Resident #3, who was admitted with diagnoses including Hemiplegia, Hemiparesis, Lack of Coordination, and Muscle Weakness. Despite the facility's policies requiring documentation of care refusals, there was no record of Resident #3's resistance to transfers with the Hoyer lift. Multiple staff members, including CNAs and nurses, confirmed that the resident had been resistant to care and mechanical lift usage, preferring the sit-to-stand lift over the Hoyer lift. However, these refusals and resistances were not documented in the medical record as required by the facility's policies on Authentication of All Record Entries and Refusal of Care or Treatment. Interviews with various staff members, including the Restorative CNA, multiple CNAs, an RN, and an LPN, revealed that they were aware of Resident #3's resistance to the Hoyer lift and had reported these incidents to the assigned nurse. Despite this, both the RN and LPN admitted to not documenting these refusals in the medical record. The Director of Nursing confirmed that it was her expectation for nurses to document any refusals of care, transfers, or behaviors in the medical record, and acknowledged that the medical record for Resident #3 was incomplete and inaccurate due to the lack of documentation of these incidents.
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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