Northbrooke Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, Tennessee.
- Location
- 121 Physicians Dr, Jackson, Tennessee 38305
- CMS Provider Number
- 445401
- Inspections on file
- 29
- Latest survey
- April 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Northbrooke Post Acute during CMS and state inspections, most recent first.
Surveyors found that three residents with pressure ulcers did not receive prescribed wound treatments on multiple occasions, and pressure-reducing mattresses were not properly implemented or maintained as ordered. Observations confirmed missing or incomplete equipment and lack of documentation for required care, with the DON acknowledging missed treatments and delays in initiating wound care.
Staff failed to properly secure and store medications, leaving drugs unattended on medication carts, storing opened oral medications in cups, and keeping a resident's inhaler at bedside without proper labeling. Multiple medication carts were found unlocked, unattended, and with damaged drawers that allowed access to medications. Staff and management confirmed these practices were not in line with facility policy.
Surveyors found that food was stored unlabeled, undated, and beyond use-by dates, with some items placed on the freezer floor and staff personal items on workstations. Dirty containers, rusted equipment, and an ice machine with debris were observed, along with uncovered drinks and food trays stored with standing water. Staff failed to perform hand hygiene or change gloves when required during food preparation and service, and nourishment refrigerators/freezers lacked proper temperature logs and thermometers, with expired or unlabeled food present.
Three cognitively intact residents with complex medical conditions were not invited to or included in required quarterly care plan meetings, as confirmed by missing documentation and resident interviews. Facility staff acknowledged that residents and their representatives were not notified or involved in the care planning process, contrary to policy requirements.
Two cognitively intact residents with significant medical conditions were unable to access their personal funds during after-hours and weekends, despite having funds available and having authorized the facility to manage their finances. Multiple residents confirmed this lack of access, and staff interviews indicated that no process was in place to provide funds outside of regular hours, contrary to facility policy.
Three residents with complex medical conditions, including dementia, hemiplegia, and kidney failure, died while in care, and their account balances were not refunded to their families or estates within the required 30-day period. The facility's Accounts Receivable staff confirmed the refunds were processed late, contrary to facility policy.
The facility did not provide or document required information about advance directives to multiple residents, including those who were cognitively intact and those with severe cognitive impairment whose representatives should have been informed. Staff confirmed that forms were incomplete and there was no evidence of education, signatures, or whether residents were offered or declined advance directives.
The facility failed to obtain a physician's order for foley catheter care and did not implement enhanced barrier precautions for a resident with an indwelling catheter, as well as failed to administer and document multiple scheduled medications for another resident with complex medical needs. Staff confirmed the absence of required orders, documentation, and medication administration.
A resident with total dependency for transfers and a history of falls was transferred using an inappropriate mechanical lift after staff failed to consult the care plan or Kardex, relying instead on the resident's verbal instruction. This resulted in the resident sliding out of the lift during the transfer, though no injuries were observed. Staff and therapy documentation confirmed the resident required a Hoyer lift with two-person assistance, and the failure to follow these interventions led to the incident.
Staff failed to ensure that enteral feeding products, syringes, and flush solutions were properly labeled for two residents with PEG tubes. Observations showed missing or incorrect labels, including absent resident names, dates, rates, and nurse initials. Both nursing and administrative staff confirmed that labeling requirements were not met.
The facility failed to obtain physician orders, follow existing orders, and accurately care plan for oxygen therapy for three residents. One resident received oxygen therapy without a physician's order, another received higher oxygen flow rates than documented and without a corresponding order, and a third was given oxygen at a rate significantly above the physician's order. The DON confirmed that orders and care plans were not properly followed or documented.
The facility did not have an RN on duty for the required 8 consecutive hours on two days, as staffing schedules showed only 6.5 and 6.12 RN hours due to the assigned RN and MDS Coordinator leaving early. The Staffing Coordinator confirmed the shortfall in RN coverage.
The facility did not post the total number of staff and actual hours worked by licensed staff responsible for resident care on the Daily Staff Posting form for all days reviewed. The Staffing Coordinator confirmed that the postings were kept on the computer and not displayed as required.
A resident with multiple serious health conditions was admitted to hospice and had a documented change to DNR status, but the facility failed to update the medical record and computer system. As a result, staff initiated CPR when the resident became unresponsive, contrary to the resident's updated wishes. Staff interviews confirmed the new POST form was not properly uploaded or reflected in the records.
Surveyors identified multiple infection control deficiencies, including staff failing to perform hand hygiene, improper use and storage of PPE, soiled linens left on resident room floors, and reusable medical equipment not being disinfected between uses. Environmental cleaning lapses were observed, such as blood-tinged gauze found on a resident's floor. Signage for isolation precautions was missing, and staff provided care to residents on Enhanced Barrier or Contact Precautions without appropriate PPE. These issues were confirmed by staff and nursing leadership.
The facility failed to properly label and administer enteral feedings for two residents. One resident's feeding and water flush bags were repeatedly unlabeled, and staff added formula without proper documentation. Another resident's feeding and water flush rates were set incorrectly, and the bags were undated and unlabeled, as confirmed by the Interim DON.
The facility was found to have unsanitary conditions in food storage and preparation, including undated food items and carbon build-up on cooking equipment. Additionally, expired milk was served to residents, with staff failing to check expiration dates. The CDM acknowledged these issues and the potential fire risk posed by the equipment condition.
The facility failed to maintain sanitary conditions during meal service and did not adhere to infection control protocols. Staff, including CNAs and an LPN, neglected proper hand hygiene and PPE use, particularly during meal service and resident care. Observations showed repeated failures in hand hygiene and PPE use, with staff admitting to not following or understanding infection control policies.
The facility failed to maintain resident dignity as CNAs entered multiple residents' rooms without knocking or announcing themselves, breaching the facility's policy on resident respect and dignity.
The facility failed to maintain a sanitary environment in several resident rooms, with observations of strong urine odors, dirty linens, and unlabeled personal items. Interviews with the Interim DON confirmed these conditions violated the facility's policy on cleanliness and resident rights.
The facility failed to provide scheduled bathing assistance for three residents, as required by their care plans. Despite policies ensuring three showers a week, records showed numerous missed showers for residents needing substantial assistance. The Interim DON confirmed the expectation for adherence to scheduled care, indicating a lapse in policy implementation.
The facility failed to provide necessary wound care and implement pressure-reducing mattresses for two residents with pressure ulcers. One resident did not receive ordered treatments for sacral and hip wounds on multiple occasions, while another resident's negative pressure wound therapy was not documented as completed. Additionally, the second resident was not placed on the prescribed air mattress. Interviews confirmed that treatments should be documented and air mattresses used for severe pressure ulcers.
The facility failed to ensure nursing staff demonstrated independent competency, as observed with two LPNs requiring coaching during routine care tasks. LPN L was coached on proper glucometer cleaning and hand hygiene, while LPN O needed guidance on administering medication via a PEG tube.
The facility failed to securely store medications as required by policy, with an LPN leaving a medication cart unlocked and unattended, and medications found at a resident's bedside. The Interim DON confirmed these actions were against policy.
Failure to Provide Pressure Ulcer Care and Implement Pressure-Reducing Devices
Penalty
Summary
Surveyors identified that the facility failed to follow physician orders and provide appropriate pressure ulcer care for three residents with pressure injuries. Facility policy required prompt assessment, evidence-based interventions, and the use of pressure-reducing mattresses for residents at risk or with existing pressure ulcers. However, medical record reviews and observations revealed that prescribed wound treatments were missed on multiple occasions for all three residents, and pressure-reducing mattresses were not properly implemented or maintained as ordered. For one resident with diabetes, anemia, and hypertension, there were missed daily wound treatments for both an unstageable pressure ulcer on the left buttock and a stage 3 pressure ulcer on the sacrum, as documented in the Treatment Administration Record. Observations showed that the resident's pressure-relief mattress lacked the required pump, and the appropriate equipment was not in place until after surveyor intervention. The DON confirmed that wound treatments should be completed and documented per physician orders, and that the correct mattress setup was necessary for wound care. Another resident with cerebrovascular disease and hemiplegia, who was at high risk for pressure ulcers, also had multiple missed wound treatments for a stage 3 sacral ulcer. This resident was observed on a bolster mattress rather than the required low air loss mattress until the equipment was changed during the survey. A third resident with severe malnutrition, diabetes, and Alzheimer's had missed wound treatments for a left heel injury and did not have a treatment order entered for a newly identified sacral deep tissue injury. Observations confirmed the absence of a pressure-relieving mattress until it was installed during the survey. The DON acknowledged that treatments were not initiated promptly and that documentation was lacking for required care.
Failure to Secure and Properly Store Medications
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were properly stored and secured, as required by facility policy and professional standards. Multiple incidents were observed where staff left medications unattended and out of sight, including a vial of insulin left on a medication cart and oral medications stored in a cup on the cart. In one instance, opened oral medications intended for a resident were found in a medication cup inside the medication cart, and the responsible LPN confirmed these were not disposed of as required. Additionally, a resident's inhaler was found stored on an over-the-bed table without an opened date, and staff confirmed this was not an appropriate storage location. Further observations revealed that medication carts on several halls were left unlocked, unattended, and out of staff sight. Staff interviews confirmed that medication carts should not be left unsecured or unsupervised, and that medications should not be left on top of carts or at residents' bedsides. The Director of Nursing and other staff acknowledged these lapses in medication security and storage practices during interviews. Physical inspection of medication carts on multiple halls revealed significant structural deficiencies, including holes and cracks in the drawers. These defects were large enough to allow access to medications stored inside, and staff confirmed awareness of the damage but had not reported it to management. The facility's failure to maintain secure storage for medications and to ensure staff compliance with medication handling protocols resulted in multiple deficiencies related to medication security and storage.
Deficient Food Storage, Sanitation, and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure that food was stored, handled, prepared, and served under sanitary conditions, as evidenced by multiple direct observations and policy reviews. Food items were found unlabeled, undated, and stored beyond their use-by dates, with some items placed directly on the freezer floor. Staff personal belongings, such as purses and phones, were observed on workstations and equipment, and food storage containers and lids were dirty with sticky residue. Additionally, a metal table and stand had visible rust, the ice machine had fuzzy debris hanging from its filter, and food trays were stored with standing water. Drinks were left uncovered, and nourishment refrigerators/freezers lacked proper temperature logs and thermometers, with some containing expired or unlabeled food items and visible residue. Staff did not consistently perform hand hygiene or change gloves when required, such as after adjusting face masks, opening refrigerators, handling carts, or plating food. Multiple instances were observed where dietary staff continued food preparation activities without washing hands or changing gloves after potential contamination. These actions were in direct violation of the facility's own policies, which require handwashing after unloading supplies and before handling food, as well as proper glove use and hand hygiene during food preparation and service. Interviews with the Certified Dietary Manager (CDM) and Director of Nursing (DON) confirmed that the observed practices were not in compliance with facility policies. The CDM acknowledged that food should be labeled and dated, not stored past use-by dates, and that food trays should not be stored with standing water. The DON confirmed that nourishment refrigerators/freezers should be clean, contain only resident food items, and have daily temperature logs. The CDM also confirmed that staff personal items should not be on workstations, and that hand hygiene should be performed when donning or removing gloves and after handling potentially contaminated items.
Failure to Involve Residents in Person-Centered Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan conference meetings were held at least quarterly for three residents who were cognitively intact and eligible to participate in their person-centered care planning. Policy review indicated that residents and their representatives should be invited to participate in care plan meetings, with documentation maintained by the social services director or designee. However, medical record reviews for three residents with various diagnoses, including end stage renal disease, osteomyelitis, atrial fibrillation, heart failure, cerebrovascular disease, and dementia, revealed that neither the residents nor their representatives were invited to or attended care plan meetings following multiple Minimum Data Set (MDS) assessments. Documentation of invitations or attendance was missing for several quarterly and annual care plan meetings. Interviews with the residents confirmed that they were not aware of or had not attended any care plan meetings. Staff interviews further confirmed that the responsibility for inviting residents and documenting attendance was not fulfilled, and that meeting notes did not reflect resident participation or signatures. The facility was also unable to provide documentation for at least one required care plan meeting. These findings demonstrate a failure to involve residents in the development and implementation of their person-centered care plans as required by facility policy.
Failure to Provide Residents with Reasonable Access to Personal Funds
Penalty
Summary
The facility failed to ensure that residents who had authorized the facility in writing to manage their personal funds had ready and reasonable access to those funds. According to facility policy, residents or their authorized representatives should be able to withdraw funds upon request and receive them within a reasonable time period. However, during a Resident Council Meeting, multiple residents reported that they did not have access to their funds during after-hours and on weekends. Specifically, two cognitively intact residents with various medical conditions, including hemiplegia, metabolic encephalopathy, diabetes, and congestive heart failure, stated they were unable to access their accounts at night and on weekends and expressed a desire for such access. An interview with the Accounts Receivable Consultant revealed that the facility did not currently have a receptionist available to dispense cash to residents after hours or on weekends, although there was an awareness of the regulatory requirement and an ongoing effort to address the issue. Review of the residents' fund management statements confirmed that funds were available for both residents, but the lack of access outside of regular hours constituted a failure to honor the residents' rights to manage their financial affairs as outlined in facility policy.
Delayed Refund of Resident Account Balances After Death
Penalty
Summary
The facility failed to refund the account balances of three residents within 30 days of their deaths, as required by its Resident Trust Policy. The policy states that all resident trust funds must be surrendered to the resident or their authorized representative within three normal banking days upon discharge or within thirty days upon death. However, for all three residents reviewed, the refunds were processed significantly later than the required timeframe. Specifically, one resident with diagnoses including hemiplegia, pressure ulcer, vascular dementia, and depression died, and the refund was processed over a month later. Another resident with kidney failure, sepsis, Parkinson's disease, and hemiplegia also had their refund delayed beyond the 30-day requirement. The third resident, who had dementia, anxiety, and dysphagia, similarly experienced a late refund. The Accounts Receivable staff confirmed that these account balances were refunded late.
Failure to Provide Advance Directive Information and Documentation
Penalty
Summary
The facility failed to provide information to residents regarding their right to formulate an advance directive, as required by both facility policy and federal regulations. Policy review indicated that residents or their representatives should be given written information about their rights to accept or refuse medical or surgical treatment and to formulate an advance directive, either prior to or upon admission. However, for 13 out of 25 residents reviewed, there was no documentation that this information or education was provided. This included both cognitively intact residents and those with severe cognitive impairment, where representatives should have been informed. Medical record reviews for these residents revealed a consistent lack of documentation regarding whether advance directives existed or if residents or their representatives had been offered the opportunity to formulate one. In several cases, residents were cognitively intact and capable of making their own decisions, yet there was no evidence that they were informed of their rights. For residents with severe cognitive impairment, there was no documentation that their legal representatives were educated or given the opportunity to formulate an advance directive on their behalf. During interviews, facility staff, including the Administrator in Training and the Social Worker, confirmed that the forms used for advance directives were incomplete and lacked necessary information. They were unable to provide evidence of what education was given, whether residents or family members had signed or initialed forms, or whether residents had been offered, declined, or assisted with advance directives. This lack of documentation and incomplete process led to the deficiency cited by surveyors.
Failure to Obtain Physician Orders and Administer Medications as Ordered
Penalty
Summary
The facility failed to obtain a physician's order for foley catheter care for one resident and failed to follow physician orders for another resident, as evidenced by policy review, medical record review, observations, and interviews. For one resident, there was no physician order for the placement or care of an indwelling urinary catheter, and no documentation of the catheter's insertion was found in the medical record. Additionally, enhanced barrier precautions, which are required for residents with indwelling medical devices, were not ordered or implemented, and there was no signage indicating these precautions in the resident's room. Staff interviews confirmed the absence of required orders and documentation. Another resident, who was severely cognitively impaired and dependent for all activities of daily living, had multiple diagnoses including diabetes, hypothyroidism, and a history of psychotic disorder. Review of this resident's medication administration records (MAR) over several months revealed numerous instances where scheduled medications, including insulin, levothyroxine, divalproex, megestrol acetate, and risperidone, were not administered as ordered. There was no documentation or explanation for the missed doses, and the MAR contained multiple blanks for scheduled medication administrations. The DON confirmed that unsigned medication administrations should be considered as not given. The deficiencies were identified through a combination of policy review, medical record review, direct observation, and staff interviews. The lack of physician orders for catheter care and enhanced barrier precautions, as well as the failure to administer and document scheduled medications, were not in accordance with facility policy or physician instructions. These findings were confirmed by staff, including the DON and nursing staff, who acknowledged the absence of required documentation and orders.
Failure to Follow Transfer Interventions Results in Resident Fall
Penalty
Summary
The facility failed to follow established interventions to prevent falls for a resident identified as being at risk. According to the care plan and therapy documentation, the resident was totally dependent for transfers and required the use of a Hoyer lift with two staff assisting. Despite this, staff used a stand-up lift, which was not appropriate for the resident's condition, resulting in the resident sliding out of the lift during a transfer from wheelchair to bed. The incident occurred after a CNA, unfamiliar with the resident's transfer needs, relied on the resident's verbal instruction rather than consulting the care plan or Kardex, as required by facility policy. Interviews with staff and review of records confirmed that the care plan and Kardex clearly documented the need for a Hoyer lift and total assistance for transfers. Both the CNA involved and another CNA admitted they did not check the care plan or Kardex before attempting the transfer. The Therapy Director and DON also confirmed that the resident's transfer method had not changed and that staff are expected to review the care plan or Kardex prior to transferring residents. The failure to follow these documented interventions led to the resident's fall, though no injuries were observed at the time.
Failure to Properly Label Enteral Feeding Supplies for Residents with Feeding Tubes
Penalty
Summary
Staff failed to provide proper care and services for residents with enteral feedings by not ensuring that enteral feeding products, syringes, and flush solutions were correctly labeled. For one resident with a history of gastrostomy, dementia, cerebral infarction, and dysphagia, observations revealed that the enteral feeding and water bottle were hung without any labeling for rate, date, resident name, time, or nurse initials. Additionally, a syringe was found undated and opened, and at one point, the feeding and water bottle were labeled with the wrong resident's name. The responsible LPN confirmed these labeling errors during interviews. For another resident with gastrostomy status, dysphagia, and Parkinson's, the enteral feeding and water bottle were also not properly labeled, with only the resident's last name present. The RN confirmed that the enteral syringe should be labeled with the nurse's initials, date, and changed every 24 hours, which was not done. The DON stated that proper labeling should include date, rate, time, nurse initials, and resident name, which was not observed in these cases.
Failure to Obtain and Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not obtaining required physician orders, not following existing physician orders, and not accurately care planning for oxygen therapy. For one resident with acute respiratory failure and other comorbidities, the facility did not have a physician's order for the ongoing oxygen therapy observed during multiple visits, despite documentation in the care plan. Another resident with respiratory failure and a tracheostomy was observed receiving oxygen at higher flow rates than documented in the care plan, and there was no physician's order specifying the correct oxygen flow rate. The care plan for this resident also did not accurately reflect the oxygen therapy being provided. A third resident with chronic obstructive pulmonary disease had a physician's order for oxygen at 2L/min via nasal cannula, but was observed receiving oxygen at 8L/min on two separate occasions. Nursing staff confirmed that the oxygen should have been set at 2L/min as per the physician's order. The DON acknowledged that staff are expected to follow physician orders and ensure care plans are accurate, but these requirements were not met for the residents reviewed.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours per day, 7 days a week, as required. Review of the daily staffing schedules and working schedules for March and April 2025 revealed that on two specific days, there was no RN coverage for the full 8 hours; instead, only 6.5 and 6.12 RN hours were documented on those days. During an interview, the Staffing Coordinator confirmed the shortfall, stating that the assigned RN and MDS Coordinator had left early on those dates, resulting in insufficient RN coverage.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the total number of staff and the actual hours worked by licensed staff responsible for resident care on the Daily Staff Posting form for all 31 days reviewed. Policy review, daily staff posting review, and interviews confirmed that the required information was not posted as mandated. During an interview, the Staffing Coordinator stated that the staff postings were kept on the computer and were not posted or printed for the company, resulting in the absence of the required daily postings.
Failure to Maintain Accurate Code Status in Medical Records
Penalty
Summary
The facility failed to maintain accurate and up-to-date medical records regarding the code status and CPR directives for a resident with multiple complex diagnoses, including acute respiratory failure, pulmonary disease, congestive heart failure, chronic kidney disease, and diabetes. The resident was admitted to hospice care, and documentation indicated a change in code status to Do Not Resuscitate (DNR) with comfort measures, as reflected on a new POST form and hospice admission paperwork. However, the medical record and physician order sheet did not reflect this change, and the resident remained listed as full code in the facility's computer system. When the resident became unresponsive, staff initiated CPR based on the outdated code status in the computer system, and EMS continued resuscitation efforts. Interviews with facility staff confirmed that the process for updating and uploading new POST forms was not followed, and the new DNR order was not properly incorporated into the resident's medical record. This failure to maintain accurate and current medical records resulted in actions that were not consistent with the resident's documented wishes and hospice care plan.
Widespread Infection Control Lapses Involving PPE, Hand Hygiene, and Environmental Cleaning
Penalty
Summary
Multiple deficiencies in infection prevention and control practices were observed throughout the facility, involving both staff actions and environmental conditions. In several instances, staff failed to adhere to established protocols for hand hygiene, use of personal protective equipment (PPE), and proper handling of soiled linens. For example, a registered nurse did not perform hand hygiene or don appropriate PPE before handling a resident's PEG tube, and several staff members failed to wear gowns and gloves when providing care to residents on Enhanced Barrier Precautions or Contact Precautions. Additionally, soiled linens were found placed on the floors of residents' rooms by staff, rather than being properly stored in designated containers, as confirmed by both direct observation and staff interviews. Environmental cleaning and disinfection lapses were also documented. In one case, a blood-tinged gauze was found on the floor of a resident's room, and the Director of Nursing confirmed this was inappropriate. Reusable medical equipment, such as a wristlet blood pressure machine, was not disinfected between uses on different residents, and staff failed to clean equipment before returning it to common areas. Enteral syringes were not properly air-dried before being stored, and staff did not consistently perform hand hygiene before or after medication administration or after removing gloves, as required by facility policy and CDC guidelines. Signage and communication regarding isolation and precautionary measures were insufficient. Residents with orders for Enhanced Barrier Precautions or Contact Precautions did not have appropriate signage on their doors, and PPE caddies were not available in relevant hallways. Staff entered and exited rooms of residents on isolation precautions without wearing required PPE, and some residents were unaware of their isolation status. These deficiencies were confirmed through interviews with staff and the Director of Nursing, who acknowledged that proper procedures were not followed in these instances.
Failure to Label and Administer Enteral Feedings Correctly
Penalty
Summary
The facility failed to ensure proper labeling and adherence to physician orders for enteral feedings for two residents. Resident #43, who was moderately cognitively impaired and required maximum assistance with activities of daily living, was observed with an unlabeled enteral feeding bag and water flush bag on multiple occasions. The feeding was set at 70 ml/hr with a 55 ml/hr water flush, but the bags were not labeled with the formula or rate of administration. Staff N added 500 ml of Glucerna 1.5 to the feeding bag without proper labeling, and the time of addition was not initially recorded. Resident #73, diagnosed with multiple severe conditions including quadriplegia and acute respiratory failure, had a physician's order for Jevity 1.5 at 65 ml/hr with a 45 ml/hr water flush. However, observations revealed the feeding was incorrectly set at 55 ml/hr and the water flush at 100 ml every 4 hours, with both bags undated and unlabeled. The Interim Director of Nursing confirmed the discrepancies and adjusted the rates to match the physician's orders, acknowledging the failure to label and date the bags as required.
Sanitation and Expired Food Issues in Dietary Services
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and service, as evidenced by several observations and interviews. During a kitchen inspection, surveyors found opened and undated packages of tater tots, hamburger patties, and hashbrowns. Additionally, there was a significant carbon build-up on the cooking stove burners and a large skillet, which the Certified Dietary Manager (CDM) acknowledged could pose a fire risk. The CDM confirmed that food items should be dated and that the condition of the cooking equipment was unacceptable. Further deficiencies were noted in the serving of expired milk to residents. Two residents reported receiving sour milk, with one resident unable to drink it and another having already consumed it despite the unpleasant taste. A CNA confirmed that she encountered expired milk on breakfast trays but did not report it, although she did replace the spoiled milk for the residents. The Dietary Aide admitted to not checking expiration dates before placing milk on meal trays, assuming the milk was safe since it was stored in the refrigerator. The CDM confirmed that expired milk should not be served to residents.
Infection Control and Hygiene Deficiencies in Meal Service and Resident Care
Penalty
Summary
The facility failed to ensure food was served under sanitary conditions and did not follow proper infection prevention and control protocols. During meal service, three staff members, including two CNAs and an LPN, did not perform proper hand hygiene. Observations revealed that one CNA repeatedly failed to wash hands between handling meal trays and interacting with residents, which is a direct violation of the facility's hand hygiene policy. Additionally, the LPN was observed handling meal trays without performing hand hygiene after touching potentially contaminated surfaces. The facility also failed to adhere to enhanced barrier precautions for residents requiring such measures. In one instance, a CNA provided incontinent care to a resident without wearing a gown, placed soiled items on the floor, and did not perform hand hygiene after removing gloves. The same CNA was observed touching medical equipment with contaminated gloves. Another LPN entered a resident's room without PPE and handled medical procedures without following proper hygiene protocols. Housekeeping staff also entered a resident's room without PPE, indicating a lack of awareness or availability of necessary protective equipment. Interviews with staff, including the Interim DON, confirmed a lack of understanding and adherence to infection control policies. Staff admitted to not seeing or understanding enhanced barrier precaution signage and not knowing the proper procedures for handling soiled items. The Interim DON acknowledged that staff should wear appropriate PPE and perform hand hygiene during resident care and meal service, highlighting a systemic issue in the facility's infection control practices.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents by not ensuring that staff members knocked and announced themselves before entering residents' rooms. This deficiency was observed during a dining period on Hall 200, where Certified Nursing Assistant (CNA) A entered the rooms of multiple residents without knocking or announcing their presence. Specifically, CNA A was observed entering the rooms of Residents #14, #71, #66, and #23 without following the proper protocol. Similarly, CNA B was observed on the same day entering the rooms of several residents without knocking or announcing themselves. This included Residents #58, #18, #32, #52, #3, #14, #71, #56, and #66. The Interim Director of Nursing confirmed during an interview that staff are expected to knock and announce themselves before entering a resident's room, indicating a clear breach of the facility's policy on promoting and maintaining resident dignity.
Facility Fails to Maintain Sanitary Environment in Resident Rooms
Penalty
Summary
The facility failed to maintain a sanitary environment in 10 out of 59 resident rooms, as evidenced by multiple observations of unsanitary conditions. These included strong urine odors, dirty gloves, and towels on the floor in bathrooms, as well as unlabeled and uncovered bath basins and bedpans. Specific instances were noted in the rooms of several residents, where bathrooms had urine odors, unflushed toilets, and brown substances on toilet seats. Additionally, privacy curtains in some rooms were stained, and floors were littered with debris, crumbs, and personal items like toothbrushes and deodorants. Interviews with the Interim Director of Nursing confirmed that these conditions were not in compliance with the facility's policy on maintaining a clean and homelike environment. The DON acknowledged that dirty linens and incontinent pads should not be left on the floor and that resident rooms should be free of odors and debris. The observations and interviews highlighted a systemic issue with housekeeping and sanitation practices within the facility, affecting the residents' right to a safe and comfortable living environment.
Failure to Provide Scheduled ADL Assistance for Bathing
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL), specifically bathing and showering, for three residents. The facility's policy mandates that residents who are unable to perform ADLs independently should receive the necessary services to maintain personal hygiene. However, the review of medical records and ADL Verification Worksheets revealed that Resident #35, who was severely cognitively impaired and required substantial assistance, did not receive scheduled showers on multiple occasions from March to May 2024. Similarly, Resident #31, who was cognitively intact but required physical help for most ADLs, and Resident #74, who was also cognitively intact but needed substantial assistance, missed several scheduled showers during the same period. The Interim Director of Nursing (DON) confirmed that residents are assigned showers based on their preferences and are supposed to receive three showers a week. Despite this, the ADL Verification Worksheets showed numerous missed shower dates for the three residents, indicating a failure to adhere to the scheduled care plan. The Interim DON acknowledged that residents should receive showers according to their schedule and preferences, highlighting a lapse in the facility's adherence to its own policies and procedures regarding resident care and hygiene.
Failure in Pressure Ulcer Management and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services to promote the healing of pressure ulcers for two residents. Resident #73, who was admitted with quadriplegia, cerebral infarction, hypertension, and pressure ulcers, did not receive the ordered wound care treatments on multiple occasions. The Treatment Administration Record (TAR) indicated that the prescribed Santyl ointment and dressings for the sacral and right hip wounds were not administered on specific dates. The Regional Nurse Consultant confirmed the omissions, and the Administrator acknowledged that treatments should be completed as ordered. Resident #189, admitted with a stage IV pressure ulcer, malnutrition, dementia, and cerebrovascular accident, also did not receive the required wound care. The resident's care plan included negative pressure wound therapy, which was not documented as completed on a scheduled date. During an observation, it was noted that the resident was not on the prescribed air mattress, which was confirmed by the LPN responsible for the resident's care. The Interim Director of Nursing (DON) could not verify if the wound care was performed, and the LPN admitted to not completing the treatment due to time constraints. The facility's failure to implement a pressure-reducing mattress and ensure wound care treatments were administered as ordered contributed to the deficiency. Interviews with the Interim DON and the Administrator confirmed that the documentation should reflect all care performed and that residents with stage 3 or 4 pressure ulcers should have air mattresses. The lack of proper documentation and adherence to care plans led to the identified deficiencies in pressure ulcer management.
Deficiency in Nursing Competency and Independent Practice
Penalty
Summary
The facility failed to ensure that all licensed nurses demonstrated independent competency in providing care and services, as observed in two instances involving LPNs. During a medication administration observation, LPN L was seen cleaning a glucometer with a Sani wipe only once, contrary to the facility's protocol, and was coached by a Regional Nurse to wipe it three times. Additionally, LPN L was reminded to wash her hands upon entering a resident's room, indicating a lack of adherence to proper hygiene practices. In another observation, LPN O experienced difficulty administering medication via a PEG tube and sought guidance from the Unit Manager present in the room. The Unit Manager coached LPN O to apply light pressure to the syringe, suggesting that LPN O was not fully competent in the procedure. These observations highlight a deficiency in ensuring that nursing staff are independently competent in their roles, as coaching was required during routine care tasks.
Medication Storage Deficiency
Penalty
Summary
The facility failed to adhere to its policy regarding the secure storage of medications, resulting in a deficiency. During an observation, it was noted that a medication cart was left unlocked and unattended in one of the seven medication storage areas. This occurred when an LPN left the cart unsecured while attending to a resident. The LPN acknowledged the oversight when questioned, confirming that the cart should not have been left unlocked. This incident was corroborated by the Interim DON, who stated that medication carts should not be left unsecured and unattended. Additionally, a separate observation revealed that medications were left at a resident's bedside, specifically Latanoprost Ophthalmic eye drops, which are used to treat high pressure inside the eye due to glaucoma. The Interim DON confirmed that medications should not be left at the bedside, indicating a failure to comply with the facility's medication storage policy. These observations highlight lapses in the facility's procedures for ensuring that all drugs and biologicals are stored in locked compartments, as required by their policy.
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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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