Nhc Healthcare, Springfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Tennessee.
- Location
- 608 8th Ave East, Springfield, Tennessee 37172
- CMS Provider Number
- 445088
- Inspections on file
- 21
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Nhc Healthcare, Springfield during CMS and state inspections, most recent first.
Multiple residents were subjected to sexual abuse, including one resident who was assaulted by another resident with cognitive impairment and another who was repeatedly abused by a visitor. Staff observed and intervened in the resident-to-resident incident, but there was a lack of immediate documentation, incomplete staff statements, and no timely reporting to authorities. The facility also failed to recognize and restrict a visitor who engaged in ongoing inappropriate sexual contact with a resident. These failures resulted in emotional harm and placed all residents at risk due to inadequate supervision, investigation, and enforcement of abuse prevention policies.
A resident with severe cognitive impairment and a history of falls was found on the floor in significant pain with an abnormally positioned leg. An LPN, without specialized training in managing fractures, repositioned the resident's leg before EMS arrived, causing the resident to scream in pain. Hospital evaluation confirmed a femur fracture with displacement. Staff interviews revealed concerns about the appropriateness of the LPN's actions and a lack of clear competency in handling such injuries, resulting in actual harm to the resident.
Two residents with cognitive impairments were involved in an incident where one was found on top of the other in bed, partially unclothed, requiring staff intervention. Although the event was witnessed and internally reported, the facility did not notify state authorities within the required two-hour timeframe, contrary to policy and regulatory requirements.
The facility did not thoroughly investigate or report an alleged abuse incident involving two residents, one with severe cognitive and physical impairments and another with moderate cognitive impairment and behavioral issues. The investigation lacked complete staff statements, physical assessments, and required documentation, and the incident was not reported to the state agency within the mandated timeframe.
The facility failed to store, prepare, and distribute food according to professional standards, risking foodborne illnesses for residents. Observations revealed unlabeled food, flying insects, and a malfunctioning dishwashing machine. Maintenance issues included peeling paint, food debris, and a lack of paper towels at the handwashing sink. Additionally, improperly labeled mighty shakes were found, with the FSS unable to confirm thawing dates. The Regional Dietician confirmed these findings.
The facility failed to provide adequate pharmaceutical services, resulting in deficiencies in medication administration and disposal. A resident did not receive timely delivery of medications, including insulin and pain medication, leading to unmanaged conditions. Another resident's medications were improperly administered via a G-Tube without checking placement. Additionally, insulin was administered without priming the pen, and discontinued medications were not disposed of properly, leading to unauthorized use by staff.
A resident's medication was misappropriated when an LPN took Zofran from the drug destruction bin and administered it to another LPN without a physician's order. The incident was discovered through facility gossip, and no formal investigation or disciplinary action was documented. The facility's failure to secure medications placed all residents at risk.
A facility failed to report the misappropriation of a resident's Zofran medication to the SSA. The medication was taken from the drug destruction box by a unit manager and administered to another unit manager without a physician's order. Despite the facility's knowledge of the incident, there was no documentation or evidence of reporting to the SSA, violating the facility's policy and placing residents at risk.
A facility failed to investigate the misappropriation of a resident's medication when a unit manager took Zofran from the drug destruction box and administered it to another unit manager without an order. Despite the incident being reported to the regional office, no disciplinary action or formal investigation was conducted, violating the facility's policy on handling such allegations.
A resident with epilepsy was admitted to the facility, and the staff failed to perform scheduled lab tests and document seizure activity as per protocol. The resident experienced multiple seizures, and the nurse on duty did not notify the physician promptly or administer necessary medication due to lack of training and orders. The resident was eventually sent to the hospital with status epilepticus and later passed away in hospice care.
The facility failed to ensure that two residents understood the binding arbitration agreements they signed, despite being cognitively intact. Both residents expressed confusion about the documents, and the Admissions Director admitted to not knowing that a legal representative should sign if the resident did not understand.
The facility failed to conduct timely performance evaluations for CNAs, as required by their policy. CNA1 had not received an evaluation for four years, and CNA3 had not received one for seven years. The Administrator confirmed the overdue evaluations, which are required annually according to the facility's Human Resources Policies and Procedures.
The facility failed to provide written notification to residents and their representatives regarding emergent hospital transfers, affecting several residents. The facility's policy did not specify the contents of the transfer notice, nor did it ensure that residents were informed about their appeal rights. Interviews revealed that while some documents were sent with residents, the SBAR form used did not include appeal rights information, indicating a systemic issue in the notification process.
The facility failed to provide bed hold notifications to residents and their representatives during hospital transfers, affecting six residents. The policy requires written notice of the bed hold policy, but documentation was lacking. The Director of Nursing confirmed the use of SBAR forms, which include bed hold information, but there was no evidence that this was communicated in writing, risking residents' bed security.
Failure to Protect Residents from Sexual Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to protect residents from sexual abuse, as evidenced by multiple incidents involving both resident-to-resident and visitor-to-resident abuse. In one incident, a severely cognitively impaired resident was found with another resident, who was moderately cognitively impaired, on top of him in bed, naked from the waist down and attempting sexual intercourse. Multiple staff members, including a CNA and LPNs, witnessed the event and had to physically remove the perpetrating resident, who was combative and had an erection. Despite the severity of the incident, there was no immediate documentation in the medical record, and the perpetrating resident remained in the facility without documented supervision until his discharge the following day. Staff interviews revealed confusion and disagreement about the nature of the incident, with some staff and administrators minimizing the sexual aspect, and others clearly identifying it as sexual abuse. The incident was not reported to law enforcement at the time, and statements from staff were either not collected or were delayed. Another incident involved a cognitively intact resident who reported to a family member that a frequent visitor had been inappropriately touching her during regular visits, including at facility activities such as bingo. The visitor admitted to the inappropriate sexual contact when confronted by a family friend. The facility's failure to recognize, evaluate, and restrict the visitor's access allowed the abuse to continue over an extended period. The resident expressed sadness, anxiety, and fear regarding the visitor's continued presence and the lack of intervention by the facility. The facility's policies required immediate investigation, documentation, and protective measures in response to allegations or suspicions of abuse. However, the investigation into the resident-to-resident incident was incomplete, with missing staff statements, lack of timely documentation, and no clear evidence of a thorough assessment of the victim. The abuse coordinator and administrator did not ensure that all required steps were taken, and there was a lack of communication and follow-up with staff and family members. The failure to implement adequate supervision and interventions for residents with known behavioral risks, as well as the failure to protect residents from abusive visitors, resulted in ongoing risk and emotional harm to vulnerable residents.
Failure to Ensure Nursing Staff Competency in Post-Fall Injury Response
Penalty
Summary
The facility failed to ensure that all nursing staff possessed the necessary competencies and skill sets to provide safe care for residents, as evidenced by an incident involving a resident with severe cognitive impairment and a history of falls. The resident, who was dependent on staff for toileting, dressing, bathing, and transfers, was found on the floor of her room after an unwitnessed fall from her wheelchair. She was discovered in significant distress, with her right lower extremity positioned abnormally near her face and her left upper extremity under her abdomen, crying and moaning in pain. Multiple staff members, including an LPN, responded to the scene. Despite the resident's obvious pain and abnormal limb positioning, the LPN on scene manipulated and repositioned the resident's right leg to what was perceived as a more natural alignment before emergency medical services arrived. This action was performed without a clear assessment of the injury's extent and without specialized training in managing potential fractures or dislocations. Several staff interviews confirmed that the LPN moved the resident's leg, which caused the resident to scream in pain. The LPN later stated that she acted to relieve the resident's pain, but acknowledged she was not trained to manipulate a potentially dislocated or fractured limb. Emergency medical personnel arrived and administered significant pain management interventions before attempting to move the resident, noting the severity of her pain and the obvious deformity of her leg. Hospital evaluation confirmed a right distal femur fracture with posterior displacement. Interviews with staff, including the DON and other nurses, revealed uncertainty and concern regarding the appropriateness of the LPN's actions, as well as a lack of clear guidance or competency in handling such situations. The incident resulted in actual harm to the resident, demonstrating a failure by the facility to ensure nursing staff were adequately trained and competent to respond appropriately to residents' needs following a fall with injury.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, for two of six sampled residents. Facility policy requires that any partner with direct or indirect knowledge of an event that might constitute abuse must report the event immediately, and not later than two hours after forming the suspicion, in accordance with federal and state law. Despite this, the facility did not report an incident involving two residents within the required timeframe. One resident, with diagnoses including dementia, delirium, and severe visual impairment, required substantial assistance with daily activities and had poor memory. Another resident, with diabetes, dementia, traumatic brain injury, and schizoaffective disorder, had moderate cognitive impairment and exhibited physical behaviors toward others. An incident occurred in which the second resident was found on top of the first resident in bed, partially unclothed and refusing to get off, requiring multiple staff members to intervene. The first resident was assessed and found to have no injuries, while the second resident was confused and required redirection. Staff interviews and written statements confirmed that the incident was witnessed and reported internally, but the required report to state authorities was not made within the mandated two-hour window. The Administrator acknowledged that the incident was not reported to the state agency and was not discussed in QAPI meetings, despite facility policy and regulatory requirements. The Director of Social Services also confirmed that such incidents should be reported within two hours and that a follow-up investigation is due on the fifth day.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to complete a thorough investigation and report the results of all investigations to the State Survey Agency within five working days of the incident for two residents reviewed for abuse. According to facility policy, any allegation of abuse must be reported immediately and investigated promptly, with results completed within five working days. However, in the case involving two residents, the facility did not follow these procedures after an incident where one resident was found on top of another in bed, which was considered an allegation of sexual abuse. Medical record reviews revealed that one resident had severe cognitive and physical impairments, including dementia, delirium, and blindness, while the other had moderate cognitive impairment and a history of physical behaviors toward others. The incident was reported to the Administrator and Director of Social Services, who responded after the residents were separated. The investigation conducted by the facility was incomplete, containing only one written staff statement and lacking documentation of a physical assessment for the resident involved, as well as missing incident reports for both residents. Further review showed that there was no documentation in the progress notes by the Abuse Coordinator regarding the incident, nor any follow-up note explaining the room change for the affected resident. Interviews with facility staff confirmed that the investigation did not include statements from all staff who witnessed the event, and the incident was not reported to the state agency as required. The lack of a comprehensive investigation and timely reporting constituted a failure to comply with both facility policy and federal regulations.
Food Storage and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards, placing residents at risk for foodborne illnesses. Observations revealed unlabeled and undated food items, such as bacon bits and a Styrofoam container with spareribs, macaroni and cheese, and potato salad, in the main kitchen's cooler. Additionally, numerous small, dark-colored flying insects were observed near the reach-in coolers, the three-compartment sink, and the floor drain. The Food Service Supervisor (FSS) confirmed the presence of these issues and was unable to provide documentation of pest control treatments. Further observations indicated that the dishwashing machine was not dispensing sanitizing solution during its cycles, with the FSS verifying the issue and subsequently attaching a new container of sanitizer. A large red spill in the walk-in freezer was noted on consecutive days, indicating it had not been cleaned promptly. The kitchen also had peeling paint above the food preparation area, food debris on electrical outlets, and food splashes on walls and ceilings. The FSS acknowledged these maintenance issues but could not produce maintenance requests. Additional deficiencies included a lack of paper towels at the handwashing sink, leading staff to air dry their hands. The FSS was unaware of who was responsible for replenishing paper towels on weekends. Observations also revealed improperly labeled and thawed mighty shakes, with the FSS unable to confirm thawing dates. The Regional Dietician confirmed these findings and mentioned plans for kitchen remodeling and maintenance staff involvement.
Pharmaceutical Service Deficiencies in Medication Administration and Disposal
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of several residents, leading to significant deficiencies. One resident, identified as R123, did not receive timely delivery of medications, including insulin, pain medication, and eye ointment, as ordered by the physician. The delay in medication delivery resulted in the resident experiencing elevated blood sugar levels and unmanaged pain. The facility's policy required medications to be obtained from the emergency box or through alternative means if not available, but this was not followed, and the resident's needs were not met. Another deficiency involved the improper administration of medications via a gastronomy tube for resident R20. The nurse failed to check the G-Tube placement before administering medications, which is a critical step to ensure safe and effective medication delivery. The facility's policy and training emphasized the importance of checking gastric residuals before administering medications, but the nurse did not adhere to these guidelines, potentially compromising the resident's safety. Additionally, the facility did not follow proper procedures for insulin administration for resident R21. The nurse did not prime the insulin pen before administering the dose, contrary to the manufacturer's instructions and facility policy. This oversight could lead to incorrect dosing of insulin, affecting the resident's blood glucose management. Furthermore, the facility failed to dispose of discontinued medications properly, as evidenced by the unauthorized use of medication from the destruction box by staff members, which was not documented or reported according to policy.
Misappropriation of Resident's Medication by LPNs
Penalty
Summary
The facility failed to protect a resident's medication from misappropriation, specifically involving the unauthorized use of Zofran, an antiemetic medication. A Licensed Practical Nurse (LPN) took the medication from the facility's drug destruction bin and administered it intramuscularly to another LPN without a physician's order. This incident was reported as a practice that had been previously tolerated, and no disciplinary action was initially taken. The incident involved Resident 76, whose medication was misappropriated. The facility's records indicated that Resident 76 had been admitted and later discharged, but the exact dates were not specified. The unauthorized use of the medication was discovered through facility gossip, and it was confirmed that the medication was taken from the drug destruction bin, which was not properly secured or documented. Interviews with various staff members, including the Administrator, Director of Nursing, and Consultant Pharmacist, revealed a lack of formal investigation and documentation regarding the incident. The facility's policy on abuse, neglect, and misappropriation of property was signed by the involved LPNs, but there was no evidence of reprimands or corrective actions documented in their personnel files. The facility's failure to safeguard medications placed all residents at risk for similar incidents.
Failure to Report Misappropriation of Resident Medication
Penalty
Summary
The facility failed to report the misappropriation of a resident's medication to the State Survey Agency (SSA), which is a requirement under federal and state law. The incident involved the misappropriation of Zofran, an antiemetic medication, which was taken from the drug destruction box by a unit manager and administered intramuscularly to another unit manager without a physician's order. This practice was admitted by the involved staff members, who claimed it was a common practice. Despite the facility's knowledge of the incident, there was no documentation or evidence that the misappropriation was reported to the SSA, as required by the facility's policy. The investigation revealed that two residents had physician orders for the medication, but one had been discharged, leaving only one resident, R76, whose medication was misappropriated. Interviews with staff, including the Director of Nursing and the Administrator, confirmed the lack of documentation and reporting of the incident. The facility's policy mandates immediate reporting of such incidents to the SSA and other relevant authorities, but this was not adhered to, placing all residents at risk of unreported misappropriation of their personal property.
Failure to Investigate Misappropriation of Resident Medication
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation of resident property, specifically involving Resident 76's medication. The incident involved a unit manager taking Zofran, an antiemetic medication, from the drug destruction box and administering it intramuscularly to another unit manager without a medical order. This practice was reportedly acknowledged by both unit managers as something they had always been able to do. Despite the Director of Nursing notifying the regional office about the incident, no disciplinary action was taken, and the facility did not conduct a formal investigation. Interviews conducted during the investigation revealed that one LPN admitted to taking Resident 76's Zofran from the destruction box and administering it to another LPN. The second LPN confirmed receiving the injection but was unaware of the medication's origin. The facility's policy on patient protection and response to allegations of misappropriation clearly defines such actions as the wrongful use of a patient's belongings without consent and mandates immediate assessment and investigation of such allegations. However, the facility did not adhere to this policy, leaving all residents at risk for uninvestigated misappropriation allegations.
Failure to Follow Seizure Protocol and Lab Orders
Penalty
Summary
The facility failed to ensure that nursing services followed orders for lab testing and adhered to the facility's Seizure and Epilepsy Clinical Protocol for a resident with a history of epilepsy. The resident was admitted with diagnoses including generalized epileptic syndrome and post-stroke epilepsy. A lab test scheduled for 2:00 AM was not performed, and there was no documentation of seizure monitoring as per the physician's orders. The staff did not document the resident's seizure activity in detail, including onset time, duration, and intervals between seizures, nor did they notify the physician immediately when the resident experienced status epilepticus. The medical record review revealed that the resident had four seizures in 20 minutes, starting at 4:55 AM. The nurse on duty increased the resident's oxygen and attempted to contact the physician, but there was no answer. The nurse called 911 after the second seizure, but the resident continued to have seizures while waiting for emergency services. The nurse did not have an order for a benzodiazepine and was not trained on the seizure protocol. The resident was eventually sent to the hospital, where they were admitted with status epilepticus and other complications. Interviews with the staff and the Medical Director highlighted that the nurse did not follow the expected protocol of notifying the physician after the first seizure to obtain necessary medication orders. The Medical Director confirmed that timely documentation and treatment were crucial, and the facility lacked an alternate provider to contact in the absence of the Medical Director. The resident was later transferred to inpatient hospice and passed away, with the facility acknowledging the lack of proper documentation and response during the seizure episodes.
Failure to Ensure Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents or their legal representatives understood the binding arbitration agreements they signed. This deficiency was identified for two residents, R224 and R226, who were both assessed to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Despite this, R224 did not recall signing the agreement and stated she did not understand it. Similarly, R226, whose agreement was signed by a friend, expressed confusion about the documents she signed, indicating she did not understand their meaning. The facility's policy on arbitration and financial agreements emphasized the importance of explaining the information and the circumstances under which it was provided. However, during interviews, the Admissions Director admitted to not being aware that a legal representative needed to sign if the resident did not understand the agreement. The director claimed to have explained the document to both residents and their friends, but it was apparent that the explanation was insufficient, as neither resident comprehended the agreement they were involved in.
Failure to Conduct Timely CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received performance evaluations on a periodic basis, which may be annually, as required by their policy. This deficiency was identified for two out of three CNAs whose personnel files were reviewed. Specifically, CNA1, hired on January 17, 2017, had not received a performance evaluation for a four-year period, with the last evaluation dated February 27, 2020. Similarly, CNA3, hired on August 7, 2000, had not received a performance evaluation for a seven-year period, with the last evaluation dated December 10, 2008. During an interview, the Administrator confirmed that the performance evaluations for CNA1 and CNA3 were overdue. The facility's policy, titled Human Resources Policies and Procedures, dated October 6, 2023, requires supervisors to complete a timely performance appraisal for every partner at least annually, with the possibility of more frequent appraisals if deemed necessary by supervisors.
Failure to Notify Residents of Hospital Transfers and Appeal Rights
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding emergent transfers to the hospital, affecting nine residents reviewed for hospitalization. The facility's policy on transfers and discharges did not specify the contents of the transfer notice, nor did it ensure that residents and their representatives were informed in writing about the transfer or discharge and the reasons for the move in a language and manner they could understand. This oversight potentially affected all residents transferred to the hospital, as they were not made aware of their appeal rights. The report details specific instances where residents were transferred to the hospital without proper documentation or notification. For example, Resident 10 was transferred to the emergency room due to respiratory distress, but there was no evidence of written notification to the resident or their representative. Similarly, Resident 37 was sent to the emergency department for shortness of breath, and Resident 17 was discharged to the hospital without documentation of the Situation, Background, Assessment, and Recommendations (SBAR) being provided to the resident or their representative. Interviews with facility staff, including the Director of Nursing, revealed that while certain documents like the face sheet and physician orders were sent with residents during transfers, the SBAR form used did not include information about the residents' appeal rights. This lack of documentation and communication was confirmed for multiple residents, indicating a systemic issue in the facility's handling of hospital transfers and the notification process.
Failure to Provide Bed Hold Notifications During Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notifications to residents and their representatives for six out of nine residents reviewed, which is a requirement when residents are transferred to a hospital or take therapeutic leave. This deficiency was identified through interviews, record reviews, and policy reviews. The facility's policy on bed hold notifications, revised in 2016, mandates that the social services department contact the legal representative to discuss the bed hold policy and ascertain the plans to reserve the bed. However, the policy did not ensure that written notice was provided to the resident or their representative in a language and manner they understand. This oversight was evident in the cases of six residents who were transferred to the hospital without receiving the required bed hold policy notification. The report details specific instances where residents were transferred to the hospital without proper documentation of the bed hold policy being provided. For example, one resident was sent to the emergency room due to respiratory distress, and another was transferred for shortness of breath, yet neither had documentation of the bed hold policy being communicated. The Director of Nursing confirmed that the Situation-Background-Assessment-Recommendation (SBAR) form, which includes bed hold information, was used during transfers, but there was no evidence that this information was provided in writing to the residents or their representatives. This lack of documentation and communication placed residents at risk of losing their beds during hospital transfers.
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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