Nhc Healthcare, Tullahoma
Inspection history, citations, penalties and survey trends for this long-term care facility in Tullahoma, Tennessee.
- Location
- 1321 Cedar Lane, Tullahoma, Tennessee 37388
- CMS Provider Number
- 445515
- Inspections on file
- 19
- Latest survey
- June 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Nhc Healthcare, Tullahoma during CMS and state inspections, most recent first.
A resident with emphysema who was receiving nebulized medications had their nebulizer mask left uncovered and open to air on the bedside table, rather than being stored in a labeled bag as required by facility policy. This improper storage was observed and confirmed by an LPN and the Infection Preventionist.
Dietary staff did not fully comply with facility policy requiring complete hair coverage during food preparation. The ADM was observed with hair protruding from her covering while preparing meals, and another staff member plated meals without a beard covering. The Food and Nutrition Director confirmed these lapses in proper hair restraint use.
Surveyors observed that the facility failed to properly contain garbage and maintain the outside dumpster area in a sanitary condition, with broken furniture, pallets, and disposable gloves scattered behind two dumpsters. Staff confirmed that these items were not disposed of properly and that the area was not kept sanitary, contrary to facility policy.
A resident receiving hospice services for a traumatic subdural hemorrhage and dementia did not have a hospice provider's plan of care available in the medical record, despite facility policy and contract requirements. Staff, including the DON and an LPN, were unaware of how to locate this plan, and confirmed it was not present in the record.
Staff did not consistently use required PPE, such as gowns and gloves, during high-contact care activities for two residents on Enhanced Barrier Precautions due to invasive devices. Additionally, three residents were not offered or assisted with hand hygiene before meals, despite needing help with personal hygiene. These lapses were confirmed through observation and staff interviews, revealing gaps in infection prevention practices.
The facility did not complete required quarterly MDS assessments within the mandated time frames for several residents with complex medical conditions, as confirmed by medical record review and staff interviews. MDS assessments were either completed late or left undated, in violation of regulatory requirements.
A resident with multiple diagnoses was admitted with an indwelling urinary catheter, which was later discontinued following a hospital stay and readmission. Despite observations and staff confirmation that the catheter was no longer present, the care plan was not updated to reflect this change.
Two residents were found with medications left unsecured at their bedsides after administration, despite facility policy requiring medications to be stored securely and only accessible to licensed staff unless a resident is assessed for self-administration. Both an RN and an LPN confirmed that no such assessments had been completed, and the DON verified the lack of documentation for self-administration for these residents.
The facility failed to accurately complete an MDS assessment for a resident admitted with multiple diagnoses, including a stage 1 pressure ulcer. The MDS inaccurately documented a stage 2 pressure ulcer, which was not supported by medical records, wound management reports, or observations. Interviews with the WCN, the resident, and the DON confirmed the inaccuracy.
The facility failed to revise the comprehensive care plans to include new fall prevention interventions after falls for two residents. Despite implementing immediate interventions, the care plans were not updated to reflect these changes, as confirmed by the DON.
A Wound Care Nurse failed to perform proper hand hygiene after removing soiled gloves and before applying new gloves while treating a resident's stage 3 pressure ulcer. The Director of Nursing confirmed the lapse in protocol, although the resident's wound showed no signs of infection during the observation.
Nebulizer Mask Not Stored per Policy After Use
Penalty
Summary
A deficiency occurred when staff failed to store a nebulizer mask appropriately for a resident who required nebulized medications. Facility policy required that after use, nebulizer equipment should be allowed to dry completely and then stored in a plastic bag labeled with the resident's name and date. The resident in question had a history of emphysema and was receiving both scheduled and PRN nebulizer treatments, as documented in the medical record and care plan. During observations, the nebulizer mask was found lying uncovered and open to air on the bedside table, rather than being stored in a bag as required. This was confirmed by both an LPN and the Infection Preventionist, who acknowledged that the mask was not stored according to facility policy. The failure to follow proper storage procedures was directly observed and verified through staff interviews.
Failure to Ensure Proper Use of Hair Coverings During Food Preparation
Penalty
Summary
Dietary workers failed to wear protective hair coverings in accordance with facility policy during food preparation in the kitchen. Observations revealed that the Assistant Dietary Manager (ADM) had hair protruding from her hair covering, leaving parts of her forehead and the back of her head uncovered while preparing desserts and salads for lunch meal service. Additionally, the Lead staff member was observed plating resident meals without a protective beard covering to cover his facial hair. The Food and Nutrition Director confirmed that all dietary workers are required to have their hair completely covered while in food preparation areas, and acknowledged that the ADM and Lead staff did not comply with this requirement.
Improper Disposal and Unsanitary Dumpster Area
Penalty
Summary
The facility failed to properly contain garbage and refuse and did not maintain the outside dumpster area in a sanitary and orderly condition. Review of the facility's waste management policy indicated that refuse containers and dumpsters should be kept in a safe and sanitary manner and checked routinely for debris, with items removed to minimize odors and conditions that attract insects and rodents. During an observation, surveyors found that the area behind two dumpsters contained four broken wooden pallets, a broken chair, a broken television, a broken table, and fifteen disposable gloves scattered on the ground. Interviews with the Food and Nutrition Director and the Maintenance Assistant confirmed that these items had not been disposed of properly and that the dumpster area was not maintained in a sanitary condition.
Missing Hospice Plan of Care in Medical Record
Penalty
Summary
The facility failed to ensure that a coordinated plan of care with the hospice provider was available in the medical record for one resident receiving hospice services. Review of facility policy and the hospice contract indicated that a written, coordinated plan of care should be developed and maintained jointly by the facility and the hospice provider, and that this plan should be present in the resident's medical record. However, upon review of the medical record for a resident admitted with traumatic subdural hemorrhage and dementia, there was no hospice provider's plan of care present. The comprehensive care plan referenced the need to develop a coordinated care plan, but the actual hospice plan of care was missing from the record. Interviews with facility staff, including an RN, the DON, and an LPN Unit Manager, revealed that they were unaware of how to locate the hospice provider's plan of care in the medical record. The LPN Unit Manager confirmed that hospice documentation was in the computer chart but acknowledged that the hospice provider's plan of care was not included in the resident's medical record. The DON also confirmed that the hospice provider's plan of care was supposed to be available in the medical record. Observation of the resident showed the individual was comfortable and without concerns at the time.
Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure proper implementation of its infection prevention and control program, specifically regarding the use of Enhanced Barrier Precautions (EBP) and hand hygiene assistance. For two residents on EBP due to the presence of invasive devices such as a PEG tube, PICC line, and indwelling urinary catheter, staff did not consistently don the required personal protective equipment (PPE) during high-contact care activities. In one instance, a CNA and an LPN repositioned a resident with a feeding tube while wearing gloves but not gowns, despite facility policy and care plans indicating that both gown and gloves were required for such activities. The staff involved were either unaware of the specific requirements or misunderstood when gowns were necessary. Additionally, another resident with a PICC line and catheter had linens changed by CNAs who did not wear any PPE, and an LPN managed the resident's PICC line with gloves only, omitting the gown. Staff interviews confirmed knowledge gaps and lapses in following EBP protocols. The report also documents failures in providing hand hygiene assistance to residents prior to meals. Three residents, each with varying levels of cognitive and physical impairment, were observed receiving meal trays without being offered or encouraged to perform hand hygiene. In each case, the CNA responsible for meal delivery did not assist or prompt the resident to clean their hands before eating. Interviews with the residents and staff confirmed that hand hygiene was not offered or performed prior to the meal service, despite facility policy and care plans indicating the need for such assistance, especially for residents with limited self-care abilities. The Director of Nursing acknowledged that staff were expected to offer hand hygiene assistance to all residents before meals and confirmed that infection prevention and control practices were not maintained during the observed meal service. The deficiencies were identified through policy review, medical record review, direct observation, and staff and resident interviews, highlighting specific instances where established infection control protocols were not followed.
Failure to Complete Quarterly MDS Assessments Within Regulatory Time Frames
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required regulatory time frames for seven residents. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manual, quarterly assessments must be completed at least every 92 days following the previous OBRA assessment, with the MDS completion date no later than 14 days after the Assessment Reference Date (ARD). Medical record reviews revealed that for seven residents with various diagnoses including heart failure, dementia, chronic kidney disease, diabetes, hypertension, anxiety disorder, polyneuropathy, adult failure to thrive, and depression, the quarterly MDS assessments were either completed late or not dated as required. Specific examples included assessments that were completed weeks after the required due dates or left undated. During an interview, the MDS Coordinators confirmed responsibility for signing and verifying the completion of MDS assessments and acknowledged that the assessments for the identified residents were completed late. The deficiency was identified through a review of medical records and staff interviews, which confirmed that the facility did not adhere to the mandated timelines for completing quarterly MDS assessments for these residents.
Failure to Update Care Plan After Discontinuation of Indwelling Catheter
Penalty
Summary
The facility failed to revise the care plan for a resident following a significant change in their medical status. The resident, who had diagnoses including heart failure, malignant neoplasm of the pancreas, and anxiety, was admitted with an indwelling urinary catheter. The comprehensive care plan documented the presence of the catheter. However, after the resident was hospitalized and subsequently readmitted without the catheter, the care plan was not updated to reflect the discontinuation of the device. Observations on multiple dates confirmed that the resident no longer had an indwelling urinary catheter. Interviews with nursing staff and the Director of Nursing further verified that the care plan had not been revised to address the change in the resident's condition. This failure was identified through facility policy review, medical record review, direct observation, and staff interviews.
Failure to Secure Medications and Assess for Self-Administration
Penalty
Summary
The facility failed to ensure that medications were stored and secured properly for two residents. According to facility policy, medications are to be stored safely, securely, and only accessible to licensed nursing personnel, with medications kept in a medication cart unless a resident has been assessed for self-administration. For one resident with heart failure, pancreatic cancer, and anxiety, an Incruse Ellipta inhaler was observed left on the bedside table after administration by an RN, who confirmed that the resident had not been assessed for self-administration. Similarly, for another resident with a history of joint replacement and emphysema, an unopened vial of Budesonide Inhalation Suspension was found on the bedside table after administration by an LPN, who also confirmed the absence of a self-administration assessment in the medical record. Both the RN and LPN acknowledged that medications should not be left at the bedside unless the resident has been properly assessed for self-administration, and the DON confirmed that neither resident had such an assessment documented. Observations and interviews confirmed that the medications were not secured or stored according to facility policy, and that the medications were accessible to the residents without proper authorization or assessment.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident admitted with multiple diagnoses, including a displaced intertrochanteric fracture of the left femur, chronic obstructive pulmonary disease, heart failure, and a stage 1 pressure ulcer of the sacral region. The admission MDS assessment inaccurately documented the presence of a stage 2 pressure ulcer, which was not corroborated by subsequent medical records, wound management reports, or direct observations by the wound care nurse (WCN). Interviews with the WCN, the resident, and the Director of Nursing (DON) confirmed that the resident only had a stage 1 pressure ulcer upon admission and no other wounds during their stay. The discrepancy was identified during a review of the Resident Assessment Instrument (RAI) Manual and through interviews and observations conducted by surveyors. The WCN and the resident both confirmed that the resident had only one stage 1 pressure ulcer, which had resolved by the time of the survey. The DON and the MDS Coordinator acknowledged that the MDS assessment completed on the specified date was inaccurate, as it incorrectly indicated the presence of a stage 2 pressure ulcer. This inaccuracy in the MDS assessment reflects a failure to provide an accurate picture of the resident's current health status as required by regulatory standards.
Failure to Revise Care Plans After Falls
Penalty
Summary
The facility failed to revise the comprehensive care plan to include added fall prevention interventions after falls for two residents. Resident #5, who has diagnoses including Osteoporosis, Pathological Fracture to the Left Femur, Dementia, and a History of Falling, experienced a fall on 1/28/2024. Despite the implementation of immediate interventions such as a non-slip pad to the wheelchair, a motion sensor, and a scoop mattress, the care plan was not updated to reflect these new interventions. Observations confirmed the presence of these interventions, and the Director of Nursing (DON) acknowledged that the care plan should have been revised accordingly but was not updated after the fall on 1/28/2024. Resident #27, with diagnoses including Parkinson's Disease, Alzheimer's Disease, Dementia, and Chronic Kidney Disease, sustained a fall on 7/11/2023. The immediate intervention was to declutter the room of trip hazards from bead boxes. However, the comprehensive care plan was not revised to include this new fall intervention. The DON confirmed that the care plan had not been updated to reflect the new intervention after the fall. Observations showed that the bead boxes were arranged to prevent blockage of the room entrance, but the care plan did not document this intervention.
Failure to Perform Proper Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention practices were followed during wound care for a resident. The Wound Care Nurse (WCN) did not perform hand hygiene after removing soiled gloves and before applying new gloves while treating a stage 3 pressure ulcer on the resident's coccyx. This lapse in protocol was observed during a wound care session, and the WCN confirmed the failure to perform hand hygiene. The Director of Nursing (DON) also confirmed that adequate hand hygiene was not performed during the wound care treatment. The resident involved was admitted with diagnoses including Multiple Sclerosis, a stage 3 pressure ulcer in the sacral region, and muscle wasting. The resident's care plan included specific instructions for wound care, which were not followed correctly by the WCN. Despite the improper hand hygiene, the resident's wound showed no signs of infection during the observation. The facility's policy on aseptic treatment technique clearly outlined the need for hand hygiene after removing soiled gloves, which was not adhered to in this instance.
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 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.
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.
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 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.
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.
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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