Majestic Gardens At Memphis Rehab & Snc
Inspection history, citations, penalties and survey trends for this long-term care facility in Memphis, Tennessee.
- Location
- 131 N Tucker, Memphis, Tennessee 38104
- CMS Provider Number
- 445150
- Inspections on file
- 32
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Majestic Gardens At Memphis Rehab & Snc during CMS and state inspections, most recent first.
A resident with a history of psychotic disorder, dementia, and hypertension was discharged, but the facility did not refund the resident's personal funds within the required 30-day period. The responsible party confirmed the refund was received late, and facility staff acknowledged the delay.
The facility failed to maintain safe hot water temperatures and provide adequate supervision, resulting in dangerously elevated water temperatures and injuries to residents. Maintenance staff lacked proper training, and there was a significant communication breakdown among the staff. Additionally, improper use of a mechanical lift led to a resident's lumbar compression fracture, and another resident fell due to inadequate supervision.
The facility failed to provide information regarding a resident's right to formulate an Advance Directive for 21 of 32 sampled residents. Despite the facility's policy, medical records revealed no documentation indicating that residents or their legal representatives were informed about their right to formulate an Advance Directive upon admission. The Director of Nursing confirmed that this should have been done.
The facility failed to provide effective housekeeping and maintenance services, resulting in strong urine odors, dirty privacy curtains, standing water in sinks, and a loose handrail. Staff interviews revealed gaps in communication and follow-through on maintenance requests, compromising residents' right to a safe, clean, and comfortable environment.
The facility failed to ensure food was stored, prepared, and served under sanitary conditions. Staff used bare hands to handle food, and multiple food items were found unlabeled and undated. The deep fryer contained dark grease and crumbs, and uncovered noodles were observed on a shelf. The Certified Dietary Manager confirmed these practices were against the facility's policies.
The facility failed to maintain safe operating equipment in four shower rooms and one elevator. Shower stalls in multiple halls were capped off due to water issues, and the 200 hall elevator had been out of order for nearly a year.
The facility failed to treat all residents with dignity and respect when three staff members, including two CNAs and one LPN, did not knock or announce themselves before entering residents' rooms during dining. The DON confirmed that staff should knock before entering a resident's room.
The facility failed to notify the Ombudsman of an emergency transfer for a resident with multiple diagnoses, including dementia and congestive heart failure. The resident was transferred to a hospital after being found on the floor, but the facility did not document the notification to the Ombudsman. A staff member confirmed that the required list had not been completed or sent.
The facility failed to accurately assess residents for BIMS scores, falls, discharge disposition, and diagnoses. One resident's quarterly MDS lacked a required BIMS assessment, another had multiple falls not reflected in the MDS, and a third had a fall not updated in the MDS. Additionally, a resident's MDS inaccurately marked Quadriplegia instead of Paraplegia, and another's discharge MDS incorrectly indicated discharge to a hospital instead of home.
The facility failed to provide scheduled bathing assistance for two residents, as evidenced by incomplete Skin Check sheets and missed showers on multiple occasions. Interviews with staff confirmed the residents' scheduled shower days and the lack of documentation.
A resident with multiple medical conditions did not receive the required monthly catheter change as per the facility's policy and physician's orders. The Director of Nursing confirmed that the catheter was not changed as scheduled, which was documented in the medical records.
The facility failed to ensure secure medication storage when medications were left unattended in a resident's room and two medication carts were found unlocked and unattended. The DON and LPNs confirmed that medications should not be left unsecured.
The facility failed to maintain accurate medical records for a resident, documenting a neurological check at 12:45 PM when the resident was not present in the facility. The resident had multiple diagnoses and severe cognitive impairment, and the error was confirmed by the Director of Nursing.
Delay in Refunding Discharged Resident's Personal Funds
Penalty
Summary
The facility failed to provide timely conveyance of personal funds for one discharged resident. According to the facility's Resident Funds Policy and Procedure, residents' personal funds and a final accounting are to be conveyed within 30 days of discharge. Medical record review showed that a resident with diagnoses including psychotic disorder with delusions, dementia, and hypertension was discharged to another facility. Documentation and interviews confirmed that the resident's personal account refund was not mailed to the responsible party until well after the 30-day requirement had passed, with both the Business Office Manager and Administrator acknowledging the delay.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards, specifically by not maintaining safe hot water temperatures and not providing adequate supervision to prevent falls and injuries. Dangerous hot water temperatures ranging from 121°F to 142°F were found in multiple resident rooms and shower rooms, posing a risk of serious injury, harm, burns, or death to residents. The facility's maintenance staff lacked proper training and failed to monitor and adjust the hot water temperatures appropriately, leading to Immediate Jeopardy (IJ) for the residents' safety. Additionally, the facility's policies and procedures for water temperature safety were not followed, and there was a significant communication breakdown among the staff regarding the issue. The Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Maintenance Team Lead were all unaware of the correct water temperature ranges and failed to take immediate corrective actions when the dangerously high temperatures were discovered. The facility's failure to properly use a mechanical lift during the transfer of a resident resulted in actual harm, with one resident sustaining a lumbar compression fracture. Another resident fell and required an emergency room visit due to the facility's failure to implement one-on-one care. The facility's policies on fall prevention and management, as well as safe and proper resident handling, were not adequately followed, leading to these incidents. The facility's census was 131, and the Immediate Jeopardy for F-689 began on 4/29/2024 and was ongoing at the time of the report.
Failure to Inform Residents About Advance Directives
Penalty
Summary
The facility failed to provide information regarding a resident's right to formulate an Advance Directive for 21 of 32 sampled residents. The facility's policy, dated December 2023, mandates that upon admission, the facility will determine if the resident has executed an advance directive and, if not, will provide information regarding the formulation of an advance directive. However, the medical records of the sampled residents revealed no documentation indicating that the residents or their legal representatives were informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. For instance, Resident #1, who was admitted with diagnoses including Abnormal Weight Loss, Cerebral Palsy, Major Depressive Disorder, and Diabetes, had a BIMS score of 14, indicating cognitive intactness. Despite this, there was no documentation in the medical record to show that the resident was informed about their right to formulate an Advance Directive. Similarly, Resident #3, with severe cognitive impairment and diagnoses such as Osteoporosis with Current Pathological Fracture and Traumatic Brain Injury, also lacked documentation of being informed about Advance Directives. The deficiency was consistent across multiple residents with varying degrees of cognitive impairment and different medical conditions. For example, Resident #14 with moderate cognitive impairment and diagnoses of Weight Loss and Epileptic Seizures, and Resident #21 with severe cognitive impairment and diagnoses of Fracture and Anxiety, both lacked documentation of being informed about Advance Directives. The Director of Nursing confirmed during an interview that all residents should have been offered or educated about Advance Directives upon admission, but the facility failed to do so for the sampled residents.
Failure to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to provide effective housekeeping and maintenance services, resulting in a non-sanitary, non-orderly, and uncomfortable environment for residents. Observations revealed strong urine odors in multiple resident rooms and hallways, dirty privacy curtains, standing water in bathroom sinks and basins, and a loose handrail in the 100 Hall. Specific instances included yellow stains on fitted sheets, brown stains on privacy curtains, and clogged sinks with standing water containing black particles. These conditions persisted over several days, indicating a lack of timely and effective cleaning and maintenance interventions. Interviews with staff confirmed that the facility's cleaning and maintenance procedures were not being followed adequately. Staff I acknowledged that privacy curtains should be assessed and changed weekly but were found stained and unchanged over several days. CNA H admitted that the maintenance issue with a resident's sink had not been reported promptly, and Staff C confirmed that the sink issue had not been entered into the facility's reporting system. The Director of Nursing also confirmed that the loose handrail in the 100 Hall needed fixing but remained unrepaired for several days. The facility's policies on preventive maintenance and resident room cleaning were not effectively implemented, leading to unsanitary and unsafe conditions. Staff interviews revealed gaps in communication and follow-through on maintenance requests, contributing to the prolonged presence of odors, stains, and standing water. These deficiencies compromised the residents' right to a safe, clean, and comfortable environment, as mandated by the facility's policies and regulatory standards.
Failure to Maintain Sanitary Conditions in Food Storage, Preparation, and Service
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served under sanitary conditions. Staff were observed using bare hands to prepare food, and multiple food items in the kitchen were found to be unlabeled and undated. Specifically, there were opened and undated packages of coconut flakes, pancake waffles, corn nuggets, mangos, and various meats in the freezer. Additionally, sandwiches were found undated and unlabeled in a metal pan, and black eye peas in the refrigerator were dated beyond their discard date. The deep fryer contained dark brown grease and crumbs, indicating it had not been cleaned or the grease changed as required. Uncovered noodles were also observed sitting on a metal shelf in a Styrofoam container. These observations were confirmed by the Certified Dietary Manager (CDM), who acknowledged that the items should have been labeled, dated, and stored properly, and that the deep fryer grease should have been changed and the fryer cleaned as scheduled. Further observations revealed that a Cook/Dietary Aide used bare hands to handle bread rolls and slices of cheese, which were then left uncovered. The CDM confirmed that staff should not use bare hands to pick up food and should be wearing gloves when handling food. These actions and inactions by the staff led to the deficiency in maintaining sanitary conditions in food storage, preparation, and service, as per the facility's policies and professional standards for food safety.
Failure to Maintain Safe Operating Equipment
Penalty
Summary
The facility failed to maintain equipment in safe operating condition for four shower rooms and one elevator. Observations revealed that shower stalls in the 100, 200, 300, and 400 hall shower rooms were capped off due to issues with water coming out of both the sprayer and the shower head simultaneously, and the water not getting hot enough. The Maintenance Director confirmed these issues and stated that repairs would require accessing behind the walls. Additionally, the 200 hall elevator was found to be out of order with caution tape and an out-of-order sign, and it was confirmed by the Healthcare Consultant that the elevator had been non-functional for nearly a year.
Failure to Knock Before Entering Residents' Rooms
Penalty
Summary
The facility failed to treat all residents with dignity and respect when three staff members, including two CNAs and one LPN, did not knock or announce themselves before entering residents' rooms during dining. Specifically, CNA S entered Resident #2's room, CNA T entered Resident #15's room, and LPN U entered both Resident #26's and Resident #29's rooms without knocking or announcing their presence. This was observed during dining on Hall 300 and Hall 400. The Director of Nursing confirmed that staff should knock before entering a resident's room.
Failure to Notify Ombudsman of Emergency Transfer
Penalty
Summary
The facility failed to notify the Ombudsman of an emergency transfer for a resident. The facility's policy required that a copy of the transfer notice be sent to the Ombudsman, potentially as a list of residents on a monthly basis. Resident #66, who had multiple diagnoses including Metabolic Encephalopathy, Dysphagia, Aphasia, Hemiplegia, Dementia, Congestive Heart Failure, Hypertension, and Contracture of the Left Hand, was admitted to the facility and later transferred to a hospital for evaluation after being found on the floor. The facility did not provide documentation that the Ombudsman was notified of this transfer. During an interview, a staff member confirmed that the Ombudsman Emergency Transfer List had not been completed or sent, and they were only informed of this requirement on the day of the interview.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to accurately assess residents for BIMS scores, falls, discharge disposition, and diagnoses for five residents. Resident #41 was admitted with multiple diagnoses, including Congenital Diaphragmatic Hernia and Alcohol and Cocaine Abuse, but the quarterly MDS did not include a required BIMS assessment. Resident #47, with diagnoses including Diabetes and Heart Failure, had multiple falls documented in progress notes and care plans, but the MDS assessments incorrectly indicated no falls prior to admission or reentry. The MDS Coordinator confirmed these assessments were coded incorrectly for falls. Resident #66, admitted with diagnoses such as Metabolic Encephalopathy and Hemiplegia, had a documented fall that was not reflected in the MDS. The MDS Coordinator acknowledged this oversight. Resident #86, with Muscle Wasting and Paraplegia, had an MDS that inaccurately marked Quadriplegia instead of Paraplegia. Lastly, Resident #128, discharged with diagnoses including Sepsis and Bipolar Disorder, had a discharge MDS indicating a BIMS of 15 and discharge to a hospital, while a physician's order indicated discharge home with family. The MDS Coordinator confirmed the resident was discharged home, not to a hospital.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure that assistance with Activities of Daily Living (ADL) related to bathing was provided for two residents. Resident #1, who has diagnoses including Spastic Quadriplegic Cerebral Palsy, Chronic Kidney Disease, Diabetes, Hypertension, and Depression, was scheduled to receive showers twice weekly. However, the facility's Skin Check sheets revealed that Resident #1 did not receive showers on three scheduled dates in April 2024. Interviews with staff confirmed that the resident should have received showers twice weekly and that the Skin Check sheets were not completed for the missed dates. Similarly, Resident #80, who has diagnoses including Peripheral Vascular Disease, Pressure Ulcers, Heart Failure, Diabetes, and Adult Failure to Thrive, was also scheduled to receive showers twice weekly. The Skin Check sheets for March and April 2024 showed that Resident #80 missed several scheduled baths. Interviews with the Director of Nursing (DON) confirmed that the resident should have received showers on the specified days and that the Skin Check sheets were incomplete. The DON acknowledged the lack of documentation and confirmed the scheduled shower days for Resident #80.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and services for an indwelling catheter for a resident with multiple diagnoses, including obstructive uropathy. The facility's policy on Foley catheter care, revised in June 2023, aims to prevent urinary tract infections by ensuring proper catheter maintenance. However, a review of the medical record revealed that the resident's catheter was not changed as ordered on April 14, 2024. This was confirmed by the Director of Nursing during an interview on May 6, 2024. The resident, who was cognitively intact with a BIMS score of 15, had an indwelling catheter and was admitted with several medical conditions, including osteomyelitis, obstructive uropathy, hemiplegia, cerebral infarction, hypertension, and arteriosclerotic heart disease. The care plan specified that the catheter should be changed monthly and as needed, but this was not documented in the April 2024 Medication Administration Record. An observation on May 1, 2024, showed the resident resting in bed with the catheter in place, but the required catheter change had not been performed as per the physician's orders.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medication was stored securely in several instances. In one case, medication was left unattended in a resident's room. Specifically, two white pills were observed on the overbed table of a resident who was lying in bed and asked for water to take her medicine. The LPN responsible for administering the medication confirmed that she left the medications at the bedside because she got busy and did not return to administer them. Additionally, two medication carts were found unlocked, unattended, and out of staff's line of sight. The Back up medication cart, which contained various over-the-counter medications, was left unlocked at the 100 hall Nurse's station. The 100 hall medication cart was also found unlocked and unattended in the 200 hall. During interviews, the DON confirmed that medication carts should not be left unlocked and unattended. The DON also explained that one nurse was responsible for residents on both the 100 and 200 halls, leading to the decision to separate medications into two carts. The LPNs involved acknowledged that they should not have left medications unattended. These actions and inactions led to the deficiency in ensuring the secure storage of medications in the facility.
Inaccurate Documentation of Neurological Check
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident, identified as Resident #66. The resident's medical record contained an inaccurate neurological check. According to the facility's policy, neurological assessments must be documented with the exact time they are performed. However, a neuro check for Resident #66 was documented at 12:45 PM on 2/21/2024, despite the resident being transported to the emergency room and not present in the facility at that time. This discrepancy was confirmed through a review of the medical record and the prehospital patient record from the fire department, which indicated that the resident left the facility at 6:25 AM and returned at 12:55 PM on the same day. The Director of Nursing acknowledged the error during an interview, stating that the resident would have been on his way to the hospital at the time the neuro check was documented. Resident #66 was admitted to the facility with multiple diagnoses, including Metabolic Encephalopathy, Dysphagia, Aphasia, Hemiplegia, Cognitive Communication Deficit, Dementia, Congestive Heart Failure, Hypertension, History of Falling, and Contracture of the Left Hand. The resident had a severe cognitive impairment, as indicated by a BIMS score of 7. On 2/21/2024, the resident was found on the floor with an open area over the left brow, prompting the need for neurological checks. The inaccurate documentation of the neuro check at 12:45 PM, when the resident was not in the facility, highlights the failure to maintain accurate medical records as per the facility's policies.
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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