Millington Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Millington, Tennessee.
- Location
- 5081 Easley Avenue, Millington, Tennessee 38053
- CMS Provider Number
- 445425
- Inspections on file
- 25
- Latest survey
- March 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Millington Healthcare Center during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment experienced unmanaged pain due to the facility's failure to administer prescribed pain medications and to assess and address pain appropriately. One resident, post-amputation, did not receive ordered Hydrocodone and suffered uncontrolled pain, leading to agitation, a fall, and serious injury. Another resident with a hip fracture after a fall did not receive pain medication before hospital transfer, despite clear signs of distress. Staff did not follow up on unavailable medications or document pain management interventions, resulting in actual harm.
Two residents with severe cognitive impairment experienced preventable incidents due to inadequate supervision and failure to implement effective interventions. One resident, recently amputated and dependent on staff, exhibited new behaviors of trying to climb out of bed that were not documented or addressed, leading to an unwitnessed fall with serious injury. Another resident eloped from the facility after being mistaken for a visitor, as her risk was not identified and her photo was not in the elopement binder. In both cases, the facility did not follow its own policies for risk identification, documentation, and intervention.
An LPN diverted controlled and non-controlled medications from multiple residents, as evidenced by law enforcement's discovery of numerous resident-labeled blister packs and controlled drug records in the LPN's possession. The facility failed to maintain required documentation and was unable to account for the disposition of many medications, impacting residents with a range of medical and cognitive conditions.
Nursing staff failed to demonstrate required competencies, including immediate reporting of abuse allegations, accurate documentation of controlled substances, and timely administration of medications as ordered. A CNA delayed reporting an abuse allegation, while multiple LPNs did not properly document or administer medications according to policy and physician orders, resulting in discrepancies and late medication passes. The DON confirmed these failures were due to staff not following established procedures despite prior education.
A facility failed to maintain accurate systems for recording, reconciling, and accounting for controlled medications, resulting in an LPN diverting large quantities of scheduled and non-scheduled drugs from numerous residents. Law enforcement discovered the LPN in possession of blister packs and loose pills, many of which were missing all or most of their contents. Medication audits revealed ongoing discrepancies between medication records and actual counts, and interviews with leadership confirmed that the drug destruction process was not properly followed, allowing the diversion to go undetected.
Administration failed to ensure proper medication management, resulting in undetected drug diversion by an LPN, lack of timely pain control for two residents with significant medical needs, and inadequate systems for controlled substance reconciliation and documentation. The DON and Administrator were unaware of missing medications and did not have effective oversight or communication processes in place.
Multiple residents did not receive their medications as scheduled, and medication administration was not accurately or promptly documented by nursing staff, including agency and PRN nurses. Residents reported missed or late medications, and audit reports confirmed that medications were often given hours after the prescribed times or not documented at all. Staff interviews revealed difficulties in keeping up with medication administration and documentation requirements.
A resident, who was cognitively intact and had multiple medical conditions, reported to a nurse that a staff member had inappropriately touched him. Although the nurse reported the allegation to administration promptly, it was discovered that the resident had first disclosed the incident to a CNA the previous night, who failed to report it immediately as required by policy. The delay in reporting the allegation to administration resulted in noncompliance with the facility's abuse prevention policy.
A resident with multiple chronic conditions received Midodrine twice daily on dialysis days instead of the prescribed once daily dose, due to an incorrectly transcribed and scheduled order. The error was not identified by staff, and the medication was administered even after an elevated blood pressure reading was recorded and not re-checked.
Failure to Provide Appropriate Pain Management Resulting in Actual Harm
Penalty
Summary
The facility failed to provide appropriate pain management consistent with professional standards of practice for two residents who required such services. One resident, who was severely cognitively impaired and dependent on staff for all care, was readmitted after a right below-the-knee amputation. Upon admission, this resident's pain was assessed as moderate to severe, and physician orders included Hydrocodone for moderate pain and Ibuprofen for mild pain. Despite these orders, the facility did not administer Hydrocodone as needed for pain, resulting in the resident experiencing uncontrolled pain, as evidenced by restlessness, trembling, and new behaviors such as attempting to climb out of bed. The resident subsequently sustained an unwitnessed fall with a head injury, leading to hospitalization and diagnosis of subarachnoid hemorrhage and a periorbital fracture. The facility lacked a system to assess and address pain in residents with cognitive impairment, and there was no documentation of pain management interventions in the care plan. Another resident, also with severe cognitive impairment and dependent on staff, sustained an unwitnessed fall. Later, the resident exhibited intense pain through verbal complaints and nonverbal cues such as hollering, grimacing, and guarding the right hip and femur. The practitioner was not immediately notified, and the resident did not receive pain medication. A STAT x-ray was ordered and obtained hours later, revealing a periprosthetic fracture. The resident was transferred to the hospital without having received pain medication prior to transfer. Documentation did not reflect administration of pain medication, and staff interviews confirmed that pain management was not provided during the period of distress. Interviews with staff and review of records revealed multiple failures, including lack of follow-up when pain medications were not available, inadequate pain assessment for cognitively impaired residents, and insufficient documentation of pain management. Staff were aware that pain medications were not delivered or available, but did not take appropriate steps to resolve the issue or utilize available emergency supplies. The facility's policies required documentation and communication regarding pain management, but these were not followed, resulting in actual harm to both residents.
Removal Plan
- Root Cause Analysis was completed.
- Facility-wide audit of all residents with pain medication orders included confirmation the ordered pain medication was available on-site.
- Order request was sent to the pharmacy for a resident needing a re-fill of pain medication; resident received medication from the E-kit until the re-fill arrived.
- Pain Assessment/Management In-service training records were reviewed, including sign-in sheets and cross-referenced with current nursing staff including agency nursing.
- All nurses currently working had received pain assessment and management in-service training.
- Nursing staff were interviewed to describe the training received related to pain assessment, monitoring, and management.
- Training was conducted in person as well as electronically via the online training software.
Failure to Prevent Falls and Elopement Due to Inadequate Supervision and Intervention
Penalty
Summary
The facility failed to implement effective interventions and provide adequate supervision to prevent falls and elopement for two residents with severe cognitive impairment. One resident, who had recently undergone a right below-knee amputation and was dependent on staff for all care, began exhibiting new behaviors of attempting to climb out of bed. These behaviors were not documented in the clinical notes or addressed in the care plan, and the only interventions listed were to encourage the resident to use the call light, ensure proper footwear, and keep items within reach. Staff interviews confirmed that the resident was confused, in significant pain, and at high risk for falls, yet the care plan was not updated to reflect the new behaviors or increased risk. The resident subsequently sustained an unwitnessed fall resulting in a head injury, subarachnoid hemorrhage, and orbital fracture, and was transferred to the emergency department. The resident was later discharged to hospice and expired. Another resident with severe cognitive impairment and a history of wandering behaviors eloped from the facility through the front door. The resident was not identified as an elopement risk on admission, and the care plan did not include interventions for wandering or elopement. The resident was able to leave the building by telling the receptionist she was a visitor, as her picture was not included in the elopement binder used to identify at-risk residents. Staff only noticed the resident was missing when she was not at her usual location, and after a search, the resident was found at a nearby pharmacy approximately 12 minutes later. The receptionist, who was new to the facility, was unaware that the resident was not a visitor and allowed her to exit the building. Policy reviews revealed that the facility's procedures required identification of hazards and risks, implementation of appropriate interventions, and monitoring for effectiveness, but these were not followed in the cases described. Documentation and communication failures contributed to the lack of timely and effective interventions for both residents. The facility did not adequately assess, document, or respond to changes in resident behavior or risk, resulting in one resident sustaining actual harm and another eloping from the facility.
Widespread Diversion of Resident Medications by LPN
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically the diversion of resident medications, including controlled substances, by a staff member. An LPN was found to have diverted medications from 13 residents over a period of time, as evidenced by law enforcement's discovery of numerous resident-labeled blister packs, both empty and partially full, in the LPN's possession. The medications included Schedule II, IV, and V controlled substances, as well as non-scheduled drugs, which were found in the LPN's car and home during a law enforcement investigation. The LPN was arrested and charged with multiple counts related to unlawful possession and intent to distribute controlled substances. The facility's policies required strict controls over the handling, storage, and documentation of controlled substances, including reconciliation at the end of each shift and proper documentation of medication disposition. However, the facility was unable to provide key documentation such as Pharmacy Electronic Shipping Manifests and Controlled Drug Record forms for many of the diverted medications. The Director of Nursing (DON) acknowledged that the facility's investigation was hampered by missing paperwork and that the LPN had been responsible for removing narcotics from the cart, particularly after residents expired or were discharged. The DON also stated that the facility's usual process for handling discontinued or expired medications involved logging and securing them until destruction, but much of the documentation was unavailable due to the law enforcement investigation. The affected residents had a range of medical conditions, including diabetes, anxiety, chronic pain, dementia, and other serious diagnoses, and many were prescribed controlled substances for pain, anxiety, or seizures. Some residents were cognitively intact and able to report missed medications, while others were severely cognitively impaired or had expired during their stay. The diversion of medications was substantiated by the physical evidence collected by law enforcement, which included hundreds of pills and numerous blister packs labeled with residents' names, as well as controlled drug record forms. The facility's inability to account for the medications and documentation contributed to the deficiency.
Failure to Ensure Competent Nursing Staff and Timely Medication Administration
Penalty
Summary
The facility failed to ensure that nursing staff, including LPNs and CNAs, demonstrated the necessary competencies and skills to provide care that maximizes residents' well-being. One CNA did not immediately report an allegation of abuse made by a cognitively intact resident, instead waiting until the following day to inform facility staff, despite having attended an abuse in-service earlier in the month. This delay in reporting was acknowledged by the CNA during an interview, where she admitted to knowing the requirement to report immediately but failed to do so. Multiple LPNs did not properly document the administration of controlled substances for several residents. Discrepancies were found between the medication cards and the Controlled Drug Records for various medications, including Lacosamide, Oxycodone-Acetaminophen, Hydrocodone-Acetaminophen, Lorazepam, Tramadol, Alprazolam, Pregabalin, and Gabapentin. These discrepancies were confirmed by the LPNs during medication cart audits and interviews, with one LPN attributing the failure to sign out medications to being busy. The DON confirmed that the facility's policy requires controlled substances to be signed out when administered and acknowledged that staff were not consistently following this policy. Additionally, nursing staff failed to administer medications according to physician orders and scheduled times for several residents. Audit reports revealed that medications were often given hours late or not documented as administered at the correct times. In some cases, residents reported not receiving their medications as scheduled, and the DON acknowledged ongoing issues with timely medication administration, particularly when agency nurses were involved. The DON stated that the issue was not due to lack of education but rather staff performance, as staff had been repeatedly instructed and in-serviced on proper procedures.
Failure to Account for and Prevent Diversion of Controlled Substances
Penalty
Summary
The facility failed to maintain an effective system for recording, reconciling, and accounting for all controlled medications, which resulted in the diversion of both scheduled and non-scheduled prescription drugs by a staff LPN. The LPN was found in possession of numerous blister packs and loose pills belonging to multiple residents, including controlled substances such as Morphine, Hydrocodone, Lorazepam, Xanax, Gabapentin, and others. Law enforcement discovered these medications during a traffic stop and subsequent search of the LPN's vehicle and home, where a total of 1,929.5 pills were seized. The LPN admitted to taking medications from deceased patients at the facility, and the investigation revealed that the facility's drug destruction process was not properly followed, allowing the LPN to remove medications without detection. Medical record reviews and law enforcement findings identified that the LPN had diverted medications from at least 31 residents, including those with complex medical histories such as diabetes, renal failure, anxiety, chronic pain, and neurological disorders. Blister packs for these residents were found in the LPN's possession, often with all or most pills missing, indicating that the medications were not administered as ordered. In several cases, controlled substance records and medication administration records did not match the actual count of medications present, and discrepancies were confirmed by nursing staff during audits. The facility's policies required strict documentation and reconciliation of controlled substances, but these procedures were not effectively implemented or monitored. Interviews with facility leadership, including the DON and Administrator, revealed that the LPN had been entrusted with the responsibility of removing narcotics from medication carts for destruction, but oversight was lacking. The DON stated that she was unaware of how the LPN was able to divert medications without being detected and that the investigation was hampered by the lack of available documentation, as much of the evidence was in law enforcement custody. Observations during medication cart audits further confirmed ongoing discrepancies in controlled substance counts for multiple residents, demonstrating a systemic failure in the facility's pharmaceutical services and controlled substance management.
Failure to Ensure Medication Management, Pain Control, and Prevention of Drug Diversion
Penalty
Summary
Facility administration failed to provide adequate fiscal resources and personnel to meet resident needs, resulting in multiple deficiencies related to medication management, staff competency, and resident safety. Policies and job descriptions required the administration and nursing leadership to ensure proper handling, documentation, and reconciliation of controlled substances, as well as timely administration of medications per physician orders. However, the administration did not identify or prevent the diversion of resident medications by an LPN, which went undetected until law enforcement notified the facility. The DON confirmed that oversight systems were lacking, and the facility did not recognize missing controlled drug record sheets or medication discrepancies prior to external notification. Residents were not provided with appropriate pain management consistent with professional standards. One resident with dementia and a recent hip fracture did not receive pain medication after a fall, despite exhibiting clear signs of pain and cognitive impairment. Another resident with a recent below-the-knee amputation and severe cognitive impairment experienced uncontrolled pain and developed new behaviors, including climbing out of bed, which led to a fall and subsequent injuries. In both cases, staff failed to assess and address pain appropriately, and physician orders for pain medication were not followed. The DON and Administrator acknowledged that staff did not communicate or escalate these issues as required. The facility also lacked effective systems for recording, reconciling, and accounting for all controlled medications. There were failures to promptly identify drug diversion, ensure medications were administered according to orders and schedules, and maintain in-date controlled substances. Interviews revealed that the Administrator was unaware of the reconciliation process and that an LPN had unsupervised access to controlled substances. The DON admitted to ongoing issues with medication administration and documentation, attributing some failures to staff performance rather than lack of education. These deficiencies affected numerous residents reviewed for drug diversion and medication management.
Failure to Accurately Document and Administer Medications as Ordered
Penalty
Summary
The facility failed to maintain accurate and timely medical records related to medication administration for six sampled residents. Facility policies required that all services provided, including medication administration, be documented in the resident's medical record immediately after administration. However, review of medical records, medication administration audit reports, and interviews revealed that medications were not consistently administered or documented according to physician orders and facility policy. In several cases, medications were documented as given hours after their scheduled times, and in some instances, there was no documentation that medications were administered at all. For example, one resident with Parkinson's Disease and other conditions had multiple medications scheduled for specific times, but the audit report showed these were documented as administered several hours late. The resident reported not receiving medications as scheduled, particularly when agency nurses were on duty. Another resident with dementia and diabetes had a medication marked as not given due to hospitalization, even though the transfer to the hospital occurred hours after the scheduled dose, and the nurse could not recall the timing of the transfer or medication administration. Additional residents with complex medical needs, including diabetes, schizophrenia, and other chronic conditions, also experienced delays in medication administration, with documentation showing medications given well outside the prescribed time frames. Interviews with residents and staff confirmed these discrepancies. Residents reported not receiving medications on time, especially during night shifts or when agency staff were present. Staff interviews revealed challenges in administering and documenting medications within the required time frames, often due to workload or unfamiliarity with procedures. The Director of Nursing acknowledged that medications were not administered or documented as scheduled and attributed some issues to agency and PRN nurses. These findings demonstrate a pattern of inaccurate and untimely documentation of medication administration, contrary to facility policy and professional standards.
Failure to Immediately Report Allegation of Abuse
Penalty
Summary
Facility staff failed to ensure that an allegation of abuse involving a resident was reported to administration immediately, as required by facility policy. The policy mandates that all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but no later than two hours after the allegation is made. In this case, a resident with a history of diabetes, HIV, depression, and encephalopathy, who was cognitively intact, reported to a nurse that a staff member had inappropriately touched him. The nurse promptly reported the allegation to the administrator and initiated further steps, including arranging for the resident to be transported to the emergency room. However, it was later revealed through interviews that the resident had initially reported the same allegation to a Certified Nursing Assistant (CNA) the night before. The CNA did not immediately report the allegation, stating that she was unable to find the nurse in charge at the time and subsequently delayed reporting until the following day. The CNA acknowledged awareness of the requirement to report such incidents immediately and expressed regret for not doing so. Interviews with other staff, including the Registered Nurse and Chief Nursing Officer, confirmed the expectation that abuse allegations must be reported within two hours. The administrator also confirmed that the incident was investigated after being reported by the nurse, but the initial delay by the CNA in reporting the resident's allegation constituted a failure to follow the facility's abuse prevention policy.
Significant Medication Error in Administration of Midodrine
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to the administration of Midodrine, a medication used to raise blood pressure. According to the physician's order, the medication was to be given once a day, 30 minutes prior to dialysis on Monday, Wednesday, and Friday. However, review of the Medication Administration Records for February and March 2025 showed that the resident received Midodrine twice a day on those days, rather than the prescribed once daily dose. This error was confirmed by both the Director of Nursing and the Nurse Practitioner, who acknowledged that the order was transcribed and scheduled incorrectly. The resident involved had multiple diagnoses, including diabetes, dependence on renal dialysis, hypothyroidism, anxiety, bipolar disorder, and insomnia, and was cognitively intact. On one occasion, the resident's blood pressure was recorded as elevated at 177/95, and there was no documentation that this elevated reading was re-checked. Despite the high blood pressure, Midodrine was administered less than an hour later. The error in medication administration was attributed to incorrect transcription and lack of verification of the order, as well as a failure to monitor and respond appropriately to elevated blood pressure readings.
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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