Maplewood Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, Tennessee.
- Location
- 100 Cherrywood Place, Jackson, Tennessee 38305
- CMS Provider Number
- 445412
- Inspections on file
- 24
- Latest survey
- March 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Maplewood Health Care Center during CMS and state inspections, most recent first.
A staffing deficiency in an LTC facility led to Immediate Jeopardy when a resident experienced a change in condition without a nurse available for assessment, resulting in a 911 call and hospital admission. Another resident missed a morning blood glucose check and medications, leading to a dangerously high blood glucose level. The deficiency was due to a nurse not reporting to work, leaving one LPN to cover two halls, and a delay in contacting the on-call nurse.
The facility failed to prevent and adequately treat pressure ulcers for two residents. One resident developed a preventable pressure ulcer on her hand due to long fingernails, while another resident with a Stage 4 sacral ulcer missed multiple treatments. The facility's records showed inconsistencies in documenting skin assessments and treatments, and the Interim DON confirmed that treatments should not be missed.
A resident with multiple diagnoses and high fall risk fell twice due to the facility's failure to implement required two-person assistance for bed mobility. The CNA involved was unaware of the care plan, leading to the resident sustaining a fractured hip. The facility's oversight resulted in actual harm to the resident.
The facility failed to maintain sanitary conditions in its kitchen, with observations of dirty floors, equipment, and carts. Additionally, the facility did not adhere to its policies for monitoring and documenting food and equipment temperatures, with numerous missing logs. Staff interviews confirmed these deficiencies, acknowledging the unclean state and lack of documentation.
The facility did not provide a private space for a Resident Council meeting, as required by policy. During the meeting, the Maintenance Director and Assistant entered the room, disrupting the residents. Interviews with the Activity Director and DON confirmed the need for privacy, highlighting a failure to adhere to policy and residents' rights.
The facility did not provide a private space for a Resident Council meeting, as required by policy. During the meeting, the Maintenance Director and Assistant entered the room, disrupting the session. Interviews with the Activity Director and DON confirmed the need for privacy during such meetings.
A resident with severe cognitive impairment was transferred to a hospital without the facility notifying the resident's legal representative, as required by policy. The facility's progress note inaccurately stated that the responsible party was aware, but the notification only occurred after the hospital informed the resident's daughter, who then contacted the facility. The Interim DON acknowledged that notification should occur within an hour of transfer.
The facility failed to maintain a sanitary environment in several resident rooms, with observations of unclean conditions such as dirty baseboards, splatter marks on blinds, and sticky floors with odors. Interviews confirmed that the facility's cleaning standards were not met, as rooms and bathrooms should be clean and odor-free.
The facility failed to report allegations of abuse and an injury of unknown origin involving three residents. A resident reported verbal abuse by a staff member, which was not reported to the state agency for nine days. Another resident, who was severely cognitively impaired, had a bruise on her forehead that was not documented or investigated. A third resident reported a physical altercation with a nurse, which was initially treated as a complaint rather than abuse. The facility acknowledged the need for documentation and investigation in these cases.
The facility failed to investigate alleged abuse incidents involving two residents. One resident, who was severely cognitively impaired, had a bruise on the forehead that was not documented or investigated. Another resident, who was cognitively intact, reported an incident involving a nurse that was not classified as abuse by the facility. The lack of thorough investigation and documentation indicates a deficiency in handling abuse allegations.
A facility failed to develop a comprehensive care plan for a resident at risk for pressure injuries. Despite the facility's policy requiring documentation and communication of interventions, the care plan lacked necessary interventions for wound care to the resident's hand. The MDS Coordinator confirmed the absence of required interventions, highlighting a failure to adhere to policy and address the resident's care needs.
The facility did not conduct a quarterly care plan conference with a resident or their family representative, as required by policy. The resident, who has multiple health issues and is dependent on staff, did not have a documented care plan meeting following their quarterly MDS assessment. Interviews confirmed the omission of the family representative in the care planning process.
A facility failed to maintain accurate records and reconcile controlled medications for a nurse observed during medication administration. Discrepancies were found in the narcotic reconciliation records for three residents, with differences between the controlled drug records and the actual counts of medications like Gabapentin, Alprazolam, and Hydrocodone/Acetaminophen. The LPN admitted to administering doses without updating the narcotic book, and the Interim DON confirmed that narcotics should be signed out immediately after administration.
The facility failed to properly store and label medications, as expired Humalog pens were found in the medication room, and an over-the-counter medication was improperly stored in a shared bathroom. The Assistant Director of Nursing and Interim DON confirmed these storage practices were incorrect.
An LPN failed to follow proper infection control procedures during ostomy care for a resident with multiple diagnoses, including Dementia and Quadriplegia. The LPN did not change gloves or wash hands after cleaning the stoma and before applying a new ostomy bag, contrary to the facility's hand hygiene policy. This was confirmed by the LPN and nursing leadership.
Staffing Deficiency Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to provide sufficient licensed nursing staff to perform necessary assessments and administer morning medications as ordered for six residents. This deficiency resulted in Immediate Jeopardy when a resident experienced a change in condition, and no nurse was available to assess the resident. The resident's spouse had to call 911, leading to the resident being evaluated in the Emergency Department and admitted to the hospital. Another resident did not receive a morning blood glucose check, scheduled insulin, or Metformin, resulting in a dangerously high blood glucose level later in the day. The facility's staffing issues were evident on a specific day when a scheduled nurse did not report to work, leaving one LPN to cover two halls with a total of 49 residents. This LPN was unable to provide care for the residents on one hall due to the workload on the other hall, which included a hospice resident requiring significant attention. The on-call nurse was not contacted until several hours into the shift, and by the time they arrived, the residents had already missed their scheduled medications and assessments. Interviews with staff and documentation reviews revealed a breakdown in communication and staffing procedures. The DON was informed early in the shift about the absence of the scheduled nurse but did not ensure that the on-call nurse was contacted promptly. The staffing coordinator was not notified until midday, and the on-call nurse did not arrive until nearly seven hours after the shift began. This delay in staffing coverage led to significant lapses in resident care, including missed medication administrations and assessments.
Removal Plan
- Education was provided to the RDCS, Administrator, and Director of Nursing by the VP of Clinical Services and the Chief Operating Officer regarding On-Call Procedures.
- The off going nurse will remain at the facility to complete medication administration and to ensure resident care is continued until the Nurse Manager on call or oncoming nurse has arrived to relieve the off going charge nurse.
- Procedure of notifying the physician following assessing all potentially affected residents for further direction of action related to delayed or missed medication administration.
- Ongoing monitoring plan to prevent recurrence.
- All hall residents were evaluated for delayed medications by the Director of Nursing and Licensed Practical Nurse.
- All applicable Residents' blood glucose levels were assessed per accucheck with physician notification completed.
- The Medical Director was notified by the DON for notification of all delayed medications and missed accuchecks and insulin administration with current blood glucose levels obtained.
- The Medical Director was included in adhoc Quality Assurance and Performance Improvement (QAPI) meeting.
- All on duty Licensed Nurses were educated by the Director of Nursing and Regional Director of Clinical Services regarding On-call procedures, communication, timely medication administration, reinstructed regarding abuse prohibition and neglect, and staffing procedures.
- The Director of Nursing and Regional Director of Clinical Services completed a Medication Administration audit for all residents.
- A Governing Body meeting was held with the Administrator, Director of Nursing, Regional Director of Clinical Services, and VP of Clinical Services to discuss the notification of immediate jeopardy.
- Adhoc QAPI meeting held with the Medical Director to share Removal and in agreement with Plan of Correction and Monitoring in place.
- The Director of Nursing and/or Assistant Director of Nursing will audit medication administration competition.
- Monitoring will occur twice daily, then twice daily during business days, then weekly thereafter during morning clinical meeting.
- The Director of Nursing will report the findings to the monthly QAPI Committee meeting.
- Removal plan was discussed and approved by Medical Director.
- The Administrator will ensure the removal plan is completed.
Failure in Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development of pressure ulcers and to treat existing ones for two residents. One resident, who was at risk due to contractures and required assistance with activities of daily living, developed a pressure ulcer on the palm of her left hand due to long fingernails digging into the skin. Despite being cognitively intact, the resident was dependent on staff for personal care, including nail trimming, which was not adequately performed. The facility's records showed inconsistencies in documenting skin assessments and treatments, and the wound was not identified in a timely manner. Another resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, had a Stage 4 pressure ulcer on the sacral area. The facility's treatment administration records revealed multiple instances where prescribed treatments for the pressure ulcer were missed. The Interim Director of Nursing confirmed that treatments should not be missed and that any missed treatments should be documented with a reason. Interviews with the treatment nurse and the Director of Nursing confirmed that the pressure ulcer on the first resident's hand was preventable and should have been identified during routine skin assessments. The facility's failure to adhere to its policies on pressure injury prevention and management, as well as the lack of documentation and follow-through on prescribed treatments, contributed to the deficiencies identified in the care of these residents.
Failure to Implement Fall Interventions Results in Resident Injury
Penalty
Summary
The facility failed to implement fall interventions for a resident, resulting in actual harm. The resident, who was admitted with multiple diagnoses including left hemiplegia, Parkinson's, and dementia, was assessed as high risk for falls. Despite this, the facility did not adhere to the care plan that required two-person assistance for bed mobility. On two separate occasions, the resident fell from the bed, sustaining injuries including a fractured hip. On the first incident, the resident was found on the floor with multiple injuries, and it was noted that two staff members were required for assistance. However, during the second incident, a CNA was providing care alone when the resident fell again, leading to a hip fracture. The CNA involved was unaware of the two-person assistance requirement, as they had just started working on that side of the facility. Interviews with staff revealed that the CNA was not informed of the resident's care plan requirements, and the RN on duty was not present during the fall. The resident, who was cognitively intact, expressed pain and was eventually transferred to the hospital for evaluation and treatment. The facility's failure to follow the established care plan and ensure adequate supervision directly contributed to the resident's injury.
Sanitation and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as evidenced by multiple observations of unclean equipment and surfaces. The kitchen floor was consistently found to be dirty with dried food crumbs and debris, and the convection oven had a significant buildup of dried food particles and a thick black sticky substance. Additionally, various carts used for meal service and storage were observed to be dirty and contained food particles. The facility also failed to adhere to its own policies regarding the monitoring and documentation of food and equipment temperatures. Logs for food temperatures, freezer temperatures, cooler temperatures, and dish machine sanitation were incomplete or missing for numerous days across several months. This lack of documentation indicates a failure to ensure that food was stored, prepared, and served at safe temperatures, and that dishwashing equipment was operating under sanitary conditions. Interviews with facility staff, including the Registered Dietician and Certified Dietary Manager, confirmed these deficiencies. The staff acknowledged the unclean state of the kitchen and the failure to document required temperature checks. The Certified Dietary Manager admitted to not enforcing the necessary standards and expressed awareness of the facility's shortcomings in maintaining compliance with state regulations.
Failure to Provide Privacy for Resident Council Meeting
Penalty
Summary
The facility failed to provide a private space for the Resident Council meeting, as required by their policy titled 'Resident Council Procedural Guide' dated 11/28/2017. During the meeting held in the Dining Room, the Maintenance Director and Maintenance Assistant entered the room and walked in front of the residents, disrupting the meeting. Interviews with the Activity Director and the Director of Nursing confirmed that a private place should be provided for uninterrupted resident council meetings, indicating a failure to adhere to the facility's policy and the residents' rights to privacy during their meetings.
Failure to Provide Private Space for Resident Council Meeting
Penalty
Summary
The facility failed to provide a private space for the Resident Council meeting, as required by their policy. The policy, dated 11/28/2017, states that residents have the right to organize and participate in resident groups and must be provided with privacy for meetings. During a Resident Council meeting in the Dining Room, the Maintenance Director and Maintenance Assistant entered the room and walked in front of the residents, disrupting the meeting. Interviews with the Activity Director and the Director of Nursing confirmed that a private place should be provided for uninterrupted resident council meetings.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify the legal representative of a resident about the resident's transfer to a hospital, which is a requirement according to the facility's policy. The policy mandates that the resident's family member or legal representative must be informed of any significant changes, including transfers or discharges. In this case, the resident, who had severe cognitive impairment due to conditions such as Dysphagia, Dementia, Alzheimer's Disease, and Gastro-Esophageal Reflux, was transferred to a hospital following episodes of vomiting. The facility's progress note indicated that the responsible party was aware of the transfer, but this notification occurred only after the hospital had already informed the resident's daughter, who then contacted the facility for confirmation. Interviews conducted during the investigation revealed that the resident's responsible party was not notified by the facility at the time of the transfer. The Interim Director of Nursing stated that the responsible party should be notified within an hour of the transfer, acknowledging that immediate notification might not occur in emergencies but should happen as soon as the resident is out of the building. This failure to promptly notify the responsible party of the resident's transfer constitutes a deficiency in the facility's adherence to its notification policy.
Facility Fails to Maintain Sanitary Environment in Resident Rooms
Penalty
Summary
The facility failed to maintain a sanitary environment in several resident rooms, as evidenced by multiple observations of unclean conditions. In Resident #3's room, dirty baseboards and window blinds with yellowish-brown splatter marks were noted. The commode had a grayish-black ring and a dark brown smear above the water line. In the shared bathroom of Residents #82 and #94, a strong odor of urine was present, and the floor was sticky with visible footprints and wheelchair marks. Dirt, crumbs, and dark streaks were observed on the floor and walls. In the room shared by Residents #34 and #61, the window valance had a thick gray dusty buildup. In the room of Residents #28 and #84, the base of the enteral feeding tube pole had a yellowish tan hardened substance, and crumbs and dirt were present on the floor. Interviews with the Administrator and the Head of Housekeeping confirmed that the facility's cleaning standards were not met, as resident rooms and bathrooms should be clean, odor-free, and without visible dust or dirt.
Failure to Report Allegations of Abuse and Injury
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving Resident #76, who was cognitively intact with a BIMS score of 15. The resident reported to a surveyor that a staff member called him a derogatory name. Although the surveyor informed the Administrator of the allegation, it was not reported to the state agency until nine days later. The Administrator acknowledged the failure to report the incident promptly. Resident #81, who was severely cognitively impaired with a BIMS score of 00, was found with a bruise on her forehead, which was not documented or investigated by the facility staff. The bruise was first noted in a progress note, but subsequent skin checks did not report it. The resident's daughter discovered the bruise when the resident was hospitalized, and the facility later acknowledged the need for documentation and investigation of the injury. Resident #307, who was cognitively intact, reported an incident where a nurse allegedly tried to take his phone, leading to a physical altercation. The resident claimed the nurse put a towel over his face, which he perceived as smothering. The incident was initially reported as a complaint rather than abuse, and the Administrator did not report it to the state agency until later. The Administrator and Social Service Director did not perceive the incident as abuse, despite the resident's account.
Failure to Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to thoroughly investigate alleged abuse incidents involving two residents. For Resident #81, who was severely cognitively impaired, a bruise was noted on the forehead, but no incident report or investigation was conducted. The bruise was first observed on 12/25/2024, but it was not documented or reported as required by the facility's policy. The resident's daughter was not informed of the incident by the facility, and the bruise was only noted when the resident was hospitalized. Interviews with staff revealed a lack of clarity on the origin of the bruise, and the Interim DON confirmed that the incident should have been documented and investigated immediately. For Resident #307, who was cognitively intact, an incident occurred where the resident called 911, alleging that a nurse attempted to take his phone and subsequently restrained him with a towel over his face. The resident reported feeling unsafe and wanted to press charges. However, the facility's administration did not classify the incident as abuse, instead treating it as a complaint. The Administrator and Social Service Director did not perceive the incident as abuse, and the facility did not conduct a thorough investigation or report it as required. The facility's failure to investigate these incidents thoroughly and document them as per policy indicates a deficiency in handling allegations of abuse. The lack of immediate and appropriate response to these incidents, including failure to notify family members and conduct proper investigations, highlights a significant oversight in the facility's adherence to its policies on abuse, neglect, and incident reporting.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident identified as being at risk for pressure injuries. The facility's policy on Pressure Ulcer Prevention and Management mandates that nursing assistants inspect the skin during baths and report any concerns to the resident's nurse in a timely manner, with interventions documented in the care plan and communicated to all relevant staff. However, the care plan for the resident, who was admitted with diagnoses including Hemiplegia, Epilepsy, and knee contractures, lacked necessary interventions for wound care to the palm of the left hand, despite the resident being cognitively intact and requiring substantial assistance with activities of daily living (ADLs). The deficiency was confirmed during an interview with the Minimum Data Set (MDS) Coordinator, who acknowledged that there should have been an intervention on the care plan for the trauma from nails to the palm of the left hand. The absence of a documented intervention in the care plan indicates a failure to adhere to the facility's policy and to address the resident's specific care needs, particularly concerning the prevention and management of pressure injuries.
Failure to Conduct Quarterly Care Plan Conference
Penalty
Summary
The facility failed to conduct a quarterly care plan conference meeting with the resident or their family representative for one of the sampled residents. According to the facility's policy, a comprehensive care plan should be developed and reviewed by an interdisciplinary team, including family members or surrogates, after each comprehensive and quarterly Minimum Data Set (MDS) assessment. However, the facility was unable to provide documentation that such a meeting was conducted for the resident's quarterly comprehensive assessment. The resident in question was admitted with multiple diagnoses, including lack of coordination, severe protein-calorie malnutrition, diabetes, heart disease, anxiety, and depression. The quarterly MDS indicated that the resident is rarely or never understood and is dependent on staff for activities of daily living. Interviews with the Social Service Director and the Regional Director of Clinical Services confirmed that the family representative was not invited to the care plan meeting, which should have been conducted quarterly with the MDS assessment completion.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to maintain accurate medication records and reconcile controlled medications for one of the registered nurses observed during medication administration. The facility's policy on medication administration requires that controlled substances be signed out in the narcotic book after administration. However, discrepancies were found in the narcotic reconciliation records for three residents. For Resident #1, the controlled drug record indicated 10 capsules of Gabapentin remaining, but only 8 capsules were found in the narcotic card. The LPN explained that doses were administered at 8 AM and noon, but the count was not updated. Similarly, for Resident #20, the controlled drug record showed 18 tablets of Alprazolam remaining, while the narcotic card had only 16 tablets. The LPN stated that doses were given at 8 AM and noon, but the narcotic book was not updated. For Resident #48, the controlled drug record indicated 11 tablets of Hydrocodone/Acetaminophen remaining, but only 10 tablets were found. The LPN admitted to administering a dose at 8 AM without updating the narcotic book. The Interim Director of Nursing confirmed that narcotics should be signed out in the narcotics book immediately after administration, indicating a failure to adhere to the facility's medication administration policy.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as evidenced by the presence of expired medications and improper storage of over-the-counter medication. During an observation in the Medication Room, eight expired Humalog Solution 100 UNIT/ML Pens were found with a use-by date of 12/19/24. The Assistant Director of Nursing confirmed that expired medications should not be present in the medication room. Additionally, an over-the-counter medication for muscle cramps was observed in a shared bathroom used by two residents. The Interim Director of Nursing confirmed that over-the-counter medications should not be stored in the bathroom.
Infection Control Breach During Ostomy Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during ostomy care, as observed with a Licensed Practical Nurse (LPN) identified as LPN E. The facility's hand hygiene policy mandates that all staff perform hand hygiene procedures to prevent the spread of infection, specifically before and after handling clean or soiled dressings. During an observation, LPN E was seen performing ostomy care for a resident without changing gloves and washing hands after cleaning the stoma area and before applying a new ostomy bag. This action was contrary to the facility's policy and was confirmed by LPN E during an interview. The resident involved in this incident was admitted with multiple diagnoses, including Dementia, Quadriplegia, Diabetes, and Heart Failure, and required total assistance for all activities of daily living. The resident had an ileostomy, and physician orders indicated that the ostomy bag should be changed every three days or as needed. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the proper procedure should have included changing gloves and washing hands after cleansing the stoma before applying a new pouch, which was not followed by LPN E.
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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