Midtown Center For Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Memphis, Tennessee.
- Location
- 141 N Mclean Blvd, Memphis, Tennessee 38104
- CMS Provider Number
- 445139
- Inspections on file
- 29
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Midtown Center For Health And Rehabilitation during CMS and state inspections, most recent first.
A medication administration error occurred when an LPN administered Albuterol Sulfate instead of the prescribed Arformoterol to a resident with severe cognitive impairment and multiple diagnoses. The facility's policy requires verification of medications with the MAR, which was not followed, leading to the error confirmed by nursing staff.
The facility failed to ensure proper infection control practices during medication administration. Three LPNs did not perform hand hygiene as required by facility policy. LPN B did not wash hands after cleaning a blood pressure cuff and before or after administering medications. LPN A failed to perform hand hygiene before donning and after doffing PPE. LPN C also did not perform hand hygiene before donning PPE. The DON confirmed the necessity of hand hygiene before and after glove use.
The facility failed to provide adequate pressure ulcer care and prevention, resulting in Immediate Jeopardy for several residents. A resident developed a pressure ulcer on the palm due to long fingernails and a stage 3 ulcer on the buttock, with no signed physician orders for treatment. Observations showed missing hand rolls and poor hygiene. Other residents also suffered from inadequate ulcer care, with inconsistent staging and treatment. Staff interviews revealed confusion and non-compliance with care plans and policies.
A resident in an LTC facility experienced pain due to long toenails, with one toenail adhering to the skin, as the facility failed to provide necessary nail care. Despite a physician's order for a podiatry consultation, the resident did not receive podiatry services until months later, after the issue was highlighted by a surveyor. The facility's policy required regular nail assessments, but staff failed to notice the resident's nail condition, resulting in actual harm.
The facility failed to educate 33 out of 34 residents on advance directives, as required by their policy. Despite varying cognitive abilities among residents, the facility did not ensure that all were informed about their rights to refuse treatment and formulate an advance directive. The Administrator confirmed that this should occur at admission, but documentation was lacking.
The facility failed to report allegations of abuse involving four residents in a timely manner, as required by their policy. A cognitively intact resident reported feeling upset due to a CNA's comments, but the incident was not reported to the state. Additionally, two moderately cognitively impaired residents alleged verbal and physical aggression from another resident, with delays in reporting these incidents to the state agency.
The facility failed to investigate alleged resident-to-resident abuse thoroughly and did not submit timely 5-day follow-up reports for two residents. Incidents involved residents with varying cognitive impairments, and the facility delayed obtaining statements and implementing interventions. The Administrator acknowledged the oversight in reporting, indicating non-compliance with required protocols.
The facility failed to ensure LPNs had the necessary competencies for wound care, leading to inadequate treatment of pressure ulcers for several residents. Competency forms for two LPNs were incomplete, and multiple residents developed facility-acquired pressure ulcers that were not documented or treated according to physician orders. The DON acknowledged awareness of the issue, and the facility had prior issues with pressure ulcers.
The facility failed to ensure proper medication storage and supervision, as medications were left unattended by nursing staff during administration. An RN and two LPNs left medications out of sight while washing hands, and a medication cart was found unlocked with an unlabeled medication. Staff interviews confirmed these actions were against facility policy.
The facility failed to properly store food in the nourishment refrigerators on the 200 and 400 halls, with multiple items found unlabeled and undated. Staff interviews confirmed that these refrigerators are for resident use only and should contain labeled and dated items, as per facility policy. Despite this, the deficiency was noted during the survey, highlighting a lapse in policy adherence.
The facility's QAPI committee failed to address issues related to pressure ulcers and nail care, resulting in deficiencies in care. Several residents developed Stage 3 pressure wounds due to inadequate assessments and monitoring. The Administrator and DON were not fully informed about the severity of the wounds, and the Medical Director was unaware of the situation. Additionally, a resident experienced harm due to inadequate nail care. These incidents highlight a lack of proper communication, oversight, and adherence to professional standards of practice.
The facility failed to follow infection control protocols during medication administration, with several nurses neglecting hand hygiene and one LPN not cleaning an insulin pen's rubber seal before use. Additionally, reusable equipment was not cleaned between residents. These actions were confirmed by staff and the DON, indicating a breach in infection prevention practices.
Two residents experienced deficiencies in wound care management. One resident had a delay in antibiotic treatment for an infected wound, while another had a diabetic ulcer that was not identified until it was necrotic. Staff interviews revealed issues with timely reporting and assessment, partly due to staffing shortages.
The facility failed to provide appropriate catheter care for two residents with indwelling catheters. One resident did not have their catheter bag changed as ordered, leading to complications and hospital intervention. Another resident lacked documented physician orders for catheter use and care, with observations showing improper catheter bag positioning. Interviews confirmed that physician orders were not consistently followed, resulting in inadequate care and increased risk of complications.
A facility failed to provide appropriate care for a resident with a PEG tube, as required by their policy. Despite the resident's severe cognitive impairment and multiple medical conditions, there was no documentation of PEG site care in the Treatment Administration Record for June and July. Observations showed ongoing PEG tube feeding, but no evidence of site care, indicating a failure to adhere to the facility's policy.
Medication Administration Error by LPN
Penalty
Summary
The facility failed to follow physician orders during medication administration for a resident, as observed with one of the nurses, LPN A. The facility's policy on medication administration requires comparing the medication source with the Medication Administration Record (MAR) to verify the resident's name and medication name. However, during an observation, LPN A administered Albuterol Sulfate 25mg/3ml per nebulizer to a resident instead of the prescribed Arformoterol. The MAR for March 2025 indicated that LPN A signed out Arformoterol as administered, but not Albuterol. The resident involved was admitted with diagnoses including Cerebral Infarction, Hemiplegia, Wheezing, Shortness of Breath, and Pneumonia, and was severely cognitively impaired. Interviews with the Assistant Director of Nursing and LPN A confirmed the medication error, and the Director of Nursing acknowledged that medications should be compared to the MAR for verification. This incident highlights a failure in adhering to the facility's medication administration policy, resulting in a medication error.
Infection Control Deficiency During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration, as observed with three LPNs. The facility's policy on medication administration and hand hygiene requires hand washing before and after administering medications and when donning or doffing gloves. However, LPN B did not perform hand hygiene after cleaning a blood pressure cuff and before or after administering medications. LPN A failed to perform hand hygiene before donning PPE, and after doffing and donning new PPE when entering and exiting a resident's room. Similarly, LPN C did not perform hand hygiene before donning PPE. During an interview, the Director of Nursing confirmed that staff should wash hands before donning and after doffing gloves.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for several residents, resulting in Immediate Jeopardy. Resident #27, who was at high risk for pressure ulcers due to contractures and immobility, developed a pressure ulcer on the palm of the left hand caused by long fingernails and a stage 3 pressure ulcer on the right buttock. The facility did not have signed physician orders for the treatment of these ulcers, and the care plan was not updated to reflect the new stage 3 ulcer. Observations revealed that Resident #27 did not have hand rolls as required by the care plan, and there was a foul odor from the resident's hands, indicating inadequate hygiene and care. Resident #78 had a stage 4 pressure ulcer on the left lateral ankle that was not consistent with the characteristics of staging, and Resident #151 developed pressure wounds on the right foot due to pressure from the footboard. The facility also failed to administer prescribed treatments for pressure ulcers for Residents #478 and #479, and Resident #478's wound was inconsistent with staging. The facility's policies on pressure ulcer prevention and management were not followed, as evidenced by the lack of comprehensive skin assessments and failure to implement and document appropriate interventions. Interviews with staff revealed a lack of knowledge and adherence to care plans and policies. CNAs and LPNs were unsure of the frequency of nail trimming and hand cleaning for Resident #27, and there was confusion about the staging and treatment of pressure ulcers. The facility's failure to provide consistent and professional care for pressure ulcers led to the development and worsening of these conditions in multiple residents, highlighting significant deficiencies in the facility's care practices.
Failure to Provide Necessary Nail Care Results in Resident Harm
Penalty
Summary
The facility failed to provide necessary nail care for a resident who was unable to perform activities of daily living independently. The resident, who was cognitively intact but dependent on staff for personal hygiene, had not received toenail care since admission. This neglect resulted in the resident experiencing pain due to long toenails, with one toenail adhering to the skin. Despite a physician's order for a podiatry consultation, the facility did not provide podiatry services until several months later, after the issue was brought to their attention by a surveyor. Observations and interviews revealed that the resident's toenails were excessively long, causing discomfort and pain. The facility's policy required regular assessments and care for residents' nails, but staff failed to notice the resident's nail condition until it was highlighted by the surveyor. The resident expressed pain and dissatisfaction with the lack of care, and the facility's failure to provide timely podiatry services resulted in actual harm to the resident.
Failure to Educate Residents on Advance Directives
Penalty
Summary
The facility failed to provide education for Advance Directives to residents or their responsible parties for 33 out of 34 sampled residents. The facility's policy, dated February 20, 2024, mandates that residents or their representatives be informed about their rights to refuse medical or surgical treatment and to formulate an advance directive. However, the facility was unable to provide documentation that this information had been offered to the majority of the residents reviewed. The medical records of the residents involved show a range of cognitive abilities, as indicated by their Brief Interview for Mental Status (BIMS) scores. Some residents, such as those with scores of 14 or 15, were cognitively intact, while others had moderate to severe cognitive impairments, with scores as low as 0. Despite these varying levels of cognitive function, the facility did not ensure that all residents or their representatives were educated about advance directives upon admission. During an interview, the facility's Administrator acknowledged that the responsibility for advance directives lies with the Admission Director at the time of admission and with Social Services within 48 hours after admission. The Administrator confirmed that advance directives should be offered and documented at the time of admission, but the facility failed to do so for the majority of the residents reviewed.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse for four residents, as required by their policy on Abuse, Neglect, and Exploitation. The policy mandates reporting all alleged violations to the Administrator, state agency, and other required agencies within specified timeframes, particularly within 24 hours if the events do not result in serious bodily injury. However, the facility did not adhere to this policy. For instance, Resident #157, who was cognitively intact, reported feeling nervous and upset due to a CNA's comments, but the allegation of verbal abuse was not reported to the state agency. The Director of Nursing decided not to report the incident after discussing it with the resident. Additionally, Resident #107, who was also cognitively intact, was involved in multiple incidents of alleged abuse. Resident #35, who was moderately cognitively impaired, alleged verbal aggression from Resident #107, but this was not reported to the state until the following day. Similarly, Resident #43, also moderately cognitively impaired, alleged physical aggression from Resident #107, and the Administrator was informed of this incident three days after it occurred. These failures to report allegations of resident-to-resident abuse in a timely manner highlight the facility's non-compliance with its own policies and state regulations.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate alleged incidents of resident-to-resident abuse for three residents and did not submit a 5-day follow-up report to the state in a timely manner for two residents. The facility's policy requires immediate investigation and documentation of abuse allegations, with reports to be made to the Administrator and relevant agencies within specified timeframes. However, the facility did not adhere to these protocols, resulting in deficiencies in handling abuse allegations. Resident #107, with intact cognition, was involved in an incident where they were alleged to have been physically aggressive toward Resident #43, who had moderately impaired cognition. The facility did not present a thorough investigation of this allegation. Additionally, Resident #35, who was moderately cognitively impaired, alleged verbal aggression from Resident #107. The facility delayed obtaining statements and implementing interventions, failing to protect the residents involved. For Resident #58, who was moderately cognitively impaired, an allegation of staff-to-resident physical abuse was reported, but the 5-day follow-up report was not submitted to the state until several months later. Similarly, Resident #98, who was severely cognitively impaired, was involved in a resident-to-resident abuse incident, and the 5-day follow-up report was also delayed. The Administrator confirmed the oversight in reporting these follow-ups, indicating a lapse in the facility's compliance with reporting requirements.
Inadequate Wound Care Competency and Management
Penalty
Summary
The facility failed to ensure that the Licensed Practical Nurses (LPNs) responsible for wound care had the necessary competencies and skills to provide adequate care for pressure ulcers. This deficiency was identified for three LPNs who were responsible for wound care for seven residents. The competency forms for LPNs A and C were incomplete, lacking documentation and signatures from a reviewer, indicating a lack of proper assessment of their skills. Several residents developed facility-acquired pressure ulcers, which were not adequately documented or treated according to physician orders. For instance, Resident #27 developed a Stage 3 pressure ulcer on the right buttock, and there were no signed physician's orders for treatment. Similarly, Resident #78 had a Stage 4 pressure ulcer on the left lateral ankle, with inconsistent assessments by LPN B. Resident #123's vascular wound worsened without timely identification by LPN C, and Resident #151's pressure ulcer progressed to Stage 3 without proper intervention. The facility also failed to perform wound care treatments as ordered for Residents #478 and #479. Resident #478's sacral and umbilicus pressure ulcers were not treated on the specified days, and Resident #479's pressure ulcer care was inconsistently performed. The Director of Nursing acknowledged awareness of the issue and confirmed that pressure ulcers should be identified before reaching Stage 3. The Area Director of Clinical Services confirmed that the facility had prior issues with pressure ulcers, indicating a pattern of inadequate wound care management.
Medication Storage and Supervision Deficiency
Penalty
Summary
The facility failed to ensure proper storage and supervision of medications, as observed in several instances involving nursing staff. On multiple occasions, medications were left unattended and out of sight during administration. Specifically, an RN left a medication cup on an overbed table while washing hands in the bathroom, and two LPNs similarly left medication trays unattended in residents' rooms while they went to wash their hands. These actions were contrary to the facility's policy, which mandates that medications must be under direct observation or locked during administration. Additionally, a medication cart on the 2nd floor was found unlocked, unattended, and out of the line of sight, with a tube of Diclofenac Sodium Gel 1% in the drawer lacking a resident's name label. The LPN responsible acknowledged the oversight, confirming that the cart should have been locked and medications properly labeled. Interviews with nursing staff and the Director of Nursing corroborated these findings, emphasizing that medication carts should be locked when not in use and medications should be labeled with the resident's name.
Improper Food Storage in Nourishment Refrigerators
Penalty
Summary
The facility failed to ensure proper storage of food items in the nourishment refrigerators located in the 200 and 400 hall nutrition rooms. Observations revealed multiple food items, including a bottle of tea, a sandwich, a water bottle, a container of watermelon, a Mexican meal, a jar of salsa, a bottle of Jungle punch, and a Snickers ice-cream bar, were unlabeled and undated. This was in violation of the facility's policy, which mandates that all food items brought in by family or visitors must be labeled and dated, and discarded if not consumed within three days. Interviews with facility staff, including the Assistant Director of Nursing (ADON), a Licensed Practical Nurse (LPN), the Administrator, and the Dietary Manager (DM), confirmed that the nourishment refrigerators are intended for resident use only and that all items should be labeled and dated. The DM noted that the kitchen was not responsible for these refrigerators and that housekeepers were tasked with discarding unlabeled and undated items on Fridays. Despite these procedures, the deficiency was identified during the survey, indicating a lapse in adherence to the facility's food storage policy.
Deficiencies in Pressure Ulcer and Nail Care Management
Penalty
Summary
The Quality Assurance Performance Improvement (QAPI) committee at the facility failed to effectively identify and address issues related to pressure ulcers and nail care for several residents. The committee did not implement appropriate actions or monitor the effectiveness of these actions, leading to deficiencies in care. Specifically, the facility's QAPI program did not adequately address the needs of residents with pressure ulcers, as evidenced by the presence of Stage 3 pressure wounds, which should have been identified and treated earlier. The facility's policy required regular assessments and monitoring, but these were not effectively carried out, resulting in the progression of pressure ulcers to more severe stages. The facility's administration and nursing leadership were not fully informed or involved in the management of pressure ulcers. The Administrator did not attend weekly wound meetings and relied on the Director of Nursing (DON) for updates, which led to a lack of awareness about the severity of the pressure wounds. The DON was aware of the presence of Stage 3 pressure wounds but did not ensure that the wound nurses were properly certified to stage these wounds. Additionally, the Medical Director was not informed about the severity of the pressure wounds, indicating a breakdown in communication and oversight within the facility's leadership. The facility also failed to provide adequate nail care for a vulnerable resident, resulting in actual harm when the resident's toenails adhered to the skin, causing pain. This incident highlights the facility's failure to provide care consistent with professional standards of practice. The lack of proper assessments, documentation, and communication contributed to the deficiencies in care, as the facility did not ensure that staff were adequately trained and informed about the residents' needs and the facility's policies.
Removal Plan
- Identification of residents affected or likely to be affected
- All residents had an updated Braden Assessment completed
- Ensure initial skin assessments were completed
- Facility policies and procedures related to skin care, wound care, and pressure injury prevention were reviewed and revised
- Provided education to all licensed nurses on the completion of the Braden Score Assessment policy, and completed treatments on all new admissions
- Daily audit of the Treatment Administration Record to ensure accurate and complete documentation of skin related treatments as ordered
- Daily audits of skin related treatments including documentation, Braden Assessments, and orders
- PIP initiated to report on above monitoring and will continue
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies during medication administration, as observed in several instances involving multiple nursing staff. Specifically, one LPN did not clean the rubber seal of an insulin pen before attaching the needle, which is a deviation from the facility's policy requiring the use of an alcohol pad to wipe the seal. Additionally, four nurses, including LPNs and an RN, did not perform appropriate hand hygiene before or after administering medications, despite the facility's policy mandating hand washing as part of the medication administration process. Furthermore, one LPN failed to clean reusable equipment, such as a blood pressure cuff, between resident uses, which is contrary to the facility's infection control practices. These observations were confirmed through interviews with the nursing staff and the Director of Nursing, who acknowledged the lapses in following the established protocols for infection control and hand hygiene. These deficiencies highlight a significant gap in the facility's adherence to its own infection prevention and control policies, potentially compromising resident safety.
Deficiencies in Wound Care Management
Penalty
Summary
The facility failed to provide appropriate care and services for wounds for two residents, leading to deficiencies in wound management. Resident #123, who had severe impaired cognition and was totally dependent on staff for activities of daily living, developed wounds on the right heel and ankle. These wounds were initially classified as pressure ulcers but were later reclassified as vascular/diabetic wounds. Despite a recommendation for antibiotics on 8/23/2024 due to signs of infection, the antibiotic treatment was delayed and not started until 8/27/2024. This delay in treatment was confirmed during interviews with the LPN and the Director of Nursing (DON), who acknowledged that the antibiotic should not have been delayed. Resident #479, who had multiple diagnoses including end-stage renal disease and diabetes, developed a diabetic ulcer on the left calf. The ulcer was not identified until it had 100% necrotic tissue, indicating a significant delay in detection and assessment. The wound continued to decline, with measurements showing an increase in size and heavy purulent drainage. During an interview, an LPN expressed concerns about the lack of timely reporting and assessment of the wound, attributing it to staffing shortages and the rushed nature of the CNAs' work. The deficiencies highlight a failure in the facility's wound care management, particularly in timely assessment, classification, and treatment of wounds. The delay in starting antibiotics for Resident #123 and the late identification of the ulcer in Resident #479 demonstrate lapses in the facility's processes for monitoring and addressing wound care needs, which were confirmed through staff interviews.
Inadequate Catheter Care for Residents
Penalty
Summary
The facility failed to provide appropriate care and services for residents with indwelling catheters, specifically for two residents. Resident #71, who was admitted with a history of urinary retention and other medical conditions, had physician orders for catheter care that were not followed. The facility did not document the required catheter bag changes every two weeks for several months, leading to complications such as urinary tract infections and severe discomfort for the resident. Despite the resident's cognitive intactness, there were multiple instances where the catheter bag was not changed as ordered, and the resident experienced pain and required hospital intervention due to a malfunctioning catheter. Resident #91, admitted with severe cognitive impairment and multiple health issues, also did not receive proper catheter care. The facility failed to have documented physician orders for the use of an indwelling urinary catheter in August 2024, and there was no evidence of catheter care being provided as required. Observations revealed that the resident's catheter bag was often elevated, which is not in line with best practices for catheter care, potentially contributing to the resident's health issues. Interviews with facility staff, including the DON and medical director, confirmed that physician orders were not consistently followed, and there was a lack of documentation regarding catheter care. The facility's failure to adhere to its own policies and physician orders for catheter care resulted in inadequate care for residents with indwelling catheters, increasing the risk of infections and other complications.
Failure to Provide PEG Tube Care
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. The facility's policy on the care and treatment of feeding tubes, revised on May 31, 2023, mandates that feeding tubes be used according to physician orders and that the resident's care plan should address the use of the feeding tube, including strategies to prevent complications. However, for one resident with severe cognitive impairment and multiple medical conditions, including dysphagia and severe protein malnutrition, the facility did not document PEG site care in the Treatment Administration Record (TAR) for June and July 2024. Observations in the resident's room on multiple occasions revealed that the PEG tube feeding was ongoing, but there was no evidence of PEG site care being performed. Additionally, enteral feeding supplements and syringes were observed on the bedside table, labeled and dated, indicating that the feeding process was being carried out, but without the necessary site care. This lack of documentation and observed care indicates a failure to adhere to the facility's policy and ensure the resident received the required PEG site care.
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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