Obion County Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Union City, Tennessee.
- Location
- 1084 East County Home Road, Union City, Tennessee 38261
- CMS Provider Number
- 445508
- Inspections on file
- 21
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Obion County Nursing Home during CMS and state inspections, most recent first.
Administration failed to maintain effective financial controls over payroll and the facility checking account after bringing payroll back in-house. The administrator, a social worker/bookkeeper, and an HR/bookkeeper all had authority to process payroll, alter pay rates, track PTO on an internal spreadsheet, and sign checks without board approval. Review of payroll records, timekeeping data, and CPA analyses showed that these three staff members received large, unauthorized cash-outs of vacation and holiday time and reported extensive overtime, far exceeding facility policy and not supported by actual work hours. Time entries for the two bookkeepers were largely manual rather than actual punches, and audit logs showed self-directed pay rate changes. Interviews with the governing board, current administration, and other staff confirmed that Medicare, Medicaid, private pay, and insurance revenues were deposited into the same account from which these inflated payroll disbursements were made, and that there were no effective checks and balances or independent verification of accrued PTO or overtime, affecting funds available for all residents’ care.
The governing body failed to provide effective oversight of the administrator, payroll system, and the facility’s primary bank account, into which Medicare, Medicaid, insurance, and private resident payments were deposited. Facility policy assigned the board responsibility for establishing management policies and ensuring the administrator reported on audits, budgets, staffing, and supplies, but the facility could not produce any governing body policy predating a recent version, and board members described limited visibility into operations. Payroll had been brought back in-house using a new bookkeeping system, and over a 19‑month period the administrator and two bookkeeping staff cashed out more than $140,000 above allowable benefits, while the board received only summarized financial data and did not review detailed payroll records or prior accruals as recommended by a CPA. Personnel manuals from later years were never presented for approval, policy changes were made without board authorization, and key office positions remained vacant, all while the board relied on verbal assurances from the administrator and annual audits as their primary checks and balances. This lack of oversight and accountability for financial operations had the potential to affect all residents receiving care.
A resident with severe cognitive impairment and total dependence for ADLs was manually transferred by two CNAs without the required mechanical lift, contrary to the care plan and facility policy. After the transfer, the resident sustained a right humerus fracture, which was not promptly reported or documented by the LPN who assessed the injury. The delay in reporting and failure to follow safe transfer protocols resulted in actual harm to the resident.
The facility failed to follow infection control practices during medication administration and wound care. An LPN used a single eyelid wipe for both eyes and did not change gloves between treatments. Another LPN administered a contaminated medication and did not change gloves between treating clean and soiled pressure ulcers. The DON confirmed these actions were against facility policies.
A resident with severe cognitive deficits was found in a wheelchair with a seat belt they could not remove, contrary to the facility's 'Restraint Free Environment' policy. Despite being identified as high risk for falls, the resident was unable to release the seat belt, which functioned as a restraint. The ADON confirmed the resident's inability to remove the belt, highlighting a failure to ensure the resident's freedom from physical restraints.
A resident with a complex medical history fell from a lift device in an LTC facility, resulting in a fracture of the left humerus. The incident occurred when the lift pad straps broke during a transfer, causing the resident to fall to the floor. Staff interviews revealed that the lift pads were supposed to be checked for fraying before use, but the facility did not contact the manufacturer about the broken sling or investigate the cause of the failure.
A facility failed to provide appropriate care for a resident with an indwelling urinary catheter. The nursing staff did not obtain a physician's order for the catheter, and the care plan did not include all necessary catheter care. The resident, who was cognitively intact and had multiple diagnoses, was observed with urine draining into a catheter bedside bag. The DON confirmed the need for an order and care plan for the catheter.
A facility failed to provide adequate dialysis care and communication for a resident with multiple diagnoses, including Stage 5 Kidney Disease. The facility did not document monitoring of the resident's vascular access site on several occasions and lacked communication with the dialysis clinic. The resident was severely cognitively impaired and required dialysis three times a week, but the facility did not consistently document the necessary monitoring and communication, leading to a deficiency.
The facility failed to accurately post nurse staffing information, with missing RN hours on multiple days. An observation confirmed the absence of RN hours on the staffing posting, and the Administrator acknowledged the requirement for accurate postings.
Two LPNs at the facility failed to adhere to medication administration protocols, resulting in an 8% error rate. One LPN did not wait the recommended time between administering two eye medications to a resident with glaucoma, while another LPN failed to give a prescribed vitamin to a resident with multiple health conditions. The DON confirmed these errors.
Failure of Administrative Oversight Allowed Payroll Mismanagement and Excessive PTO Cash-Outs
Penalty
Summary
Administration failed to ensure appropriate checks and balances over the facility’s payroll system and checking account after payroll was brought back in-house. The governing body had appointed an appropriately licensed administrator who, per job description, was responsible for overall facility operations, instituting controls to ensure efficient and economical operation, limiting overtime, certifying payrolls, and ensuring timely deposits. However, the personnel plan and benefit structure implemented by the administrator was not approved by the governing body, and the facility relied on a manually maintained spreadsheet for tracking staff vacation, sick, holiday, and compensatory time. Staff could not independently verify their accrued time and had to rely on the social worker/bookkeeper to report balances. When payroll was moved from an outsourced vendor back into the facility, three office staff members—the administrator, the social worker/bookkeeper, and the HR/bookkeeper—had access to payroll records, the bookkeeping system, and the facility’s checking account, and all three could sign checks without board approval. Review of W-2s and payroll stubs showed that, after payroll was brought in-house, these three employees received large increases in total compensation, including substantial cash-outs of vacation and holiday time and significant overtime payments. Timeclock records showed that for the two bookkeepers, most time entries were manually entered rather than recorded by actual punches, and both reported very high overtime hours despite interview statements from another RN/administrative assistant that these two did not work overtime. The benefit plan limited vacation cash-out to no more than three days per pay period, but payroll records and CPA analysis showed that the three employees cashed out holiday and vacation time far in excess of policy limits. External CPA review of payroll and bank activity over a 19‑month period identified that the social worker/bookkeeper, HR/bookkeeper, and administrator collectively received $142,627.44 more in holiday and vacation cash-outs than allowed by facility policy, even under generous assumptions about maximum accruals. The bookkeeping system audit trail showed that the social worker/bookkeeper changed her own hourly rate and the administrator’s hourly rate upward during the audit period, then changed them back. Interviews with the board chairman, the current administrator, the RN administrative assistant, and the business office manager confirmed that the three office staff controlled which bills were paid, wrote and signed checks, and processed payroll without effective oversight or dual controls. The chairman reported that the three employees “took the money from the bank account,” which was funded by Medicare, Medicaid, private pay, and insurance revenues, and acknowledged that the facility was probably not administered as it should have been. The surveyor concluded that administration failed to provide oversight of payroll and staff with access to the checking account, resulting in financial mismanagement that had the potential to affect all residents whose care depended on those funds. The facility’s own policies required the administrator to implement procedures and controls to meet budgetary projections, limit overtime, and ensure efficient operation, and the board of directors was to oversee administration with proposals directed to them for consideration. Nonetheless, the administrator relied on the payroll clerk’s spreadsheet for tracking compensated absences, did not verify her own pay or the pay of the two bookkeepers, and did not monitor overtime or cash-outs against policy limits. The auditors found no reliable compensated absences report to support the large cash-outs, and the administrator acknowledged that she trusted staff under her, did not review her check stubs, and did not check the bookkeepers’ time even though she knew they were not working overtime. The lack of segregation of duties, absence of independent verification of accrued time, and failure to require board approval or dual signatures for payroll-related disbursements allowed the three employees to manipulate payroll and cash-outs using funds derived from Medicare, Medicaid, private pay, and insurance payments for resident care.
Governing body failed to oversee administrator, payroll, and facility bank account
Penalty
Summary
The deficiency involves the governing body’s failure to provide effective oversight of facility management and financial operations, including payroll and the primary facility bank account into which Medicare, Medicaid, insurance, and private resident payments were deposited. Facility policy dated 10/9/2025 stated that the governing body was legally responsible for establishing and implementing policies for management and operation of the facility, appointing an administrator who was responsible for management, and ensuring a process for the administrator to report on audits, budgets, staffing, and supplies. The facility was unable to produce any governing body policy that was in effect prior to 10/9/2025. Board members and the chairman described their role as mainly policy-making and oversight, with the administrator as the only employee of the board, but they relied largely on verbal reports and limited written financial information from the administrator. Governing body minutes showed that payroll had been brought back in-house after previously being outsourced, and that a new bookkeeping system was implemented. Over multiple meetings, the board received high-level financial reports from a CPA, including reports of profits and losses, but there were gaps in financial reporting, such as a meeting where financials were not reported due to the absence of the administrator and CPA. The minutes also documented that personnel manuals from 2022 and 2023 were never presented to the board for approval, even though earlier manuals had been approved, and that key office positions such as Social Services, Human Resources, and Business Office Manager were vacant. Board members later learned that policy manuals had been revised without board approval and that multiple versions of the policy manual were in circulation. A spreadsheet from CPA Firm #1 covering a 19‑month period showed that the administrator and two bookkeeping staff cashed out a total of $142,627.44 over the maximum benefit allowed by facility policy. An analysis from the CPA identified three employees who far exceeded the window for payroll payouts after payroll was brought back in-house and recommended that the board review prior auditors’ accruals for vacation, holiday, and sick leave and interview prior administrators about vacation restrictions during COVID. The chairman later acknowledged that he did not think the board had reviewed those accruals or discussed the CPA’s letter. Interviews with board members revealed that their primary checks and balances were annual audits and review of summarized financial statements, that they did not have detailed visibility into payroll or individual salaries, and that they were unaware of staff turning in hours worked at home. The board members stated they were blindsided when an external auditor identified significant unexplained salary increases for the administrator and two bookkeeping staff, and they acknowledged that the governing body had “dropped the ball” on ensuring the administrator was held accountable and that policy changes and financial operations were properly reviewed. The failure of the governing body to oversee the administrator, payroll system, and bank account was determined to have the potential to affect all 45 residents in the facility. The chairman reported that during the tenure of a prior administrator, payroll had been outsourced to an out-of-state firm without the board’s knowledge, which contributed to that administrator’s departure. Afterward, the administrator and a bookkeeper recommended bringing payroll back in-house, and the board accepted their assurances that there were no problems. The chairman stated that he questioned the administrator and visited the facility but relied on the information provided and did not receive the level of financial detail he felt was needed. Board members described that they received total salary figures as a blanket line item and general expense breakdowns, but not detailed salary registers or clear tracking of compensated absences. One board member stated that the governing body’s oversight and visibility into operations were limited and that they had not been given copies of the policy manual, despite the policy requiring a process for holding the administrator accountable for reporting on management and operations. Another board member linked the unapproved 2023 personnel handbook changes, including wording that allowed staff to cash in time, to the financial issues, noting that the way the policy was written contributed to increased payouts. Throughout interviews, board members and the chairman acknowledged that they relied heavily on trust in the administrator and did not implement or follow through on robust checks and balances to detect or prevent mismanagement of payroll and the facility’s bank account.
Failure to Follow Safe Transfer Policy and Timely Injury Reporting Results in Resident Harm
Penalty
Summary
Facility staff failed to follow established policy for safe resident handling and transfer, resulting in harm to a cognitively impaired resident who required two-person assistance and a mechanical lift for all transfers. On the day of the incident, two CNAs transferred the resident from bed to a shower chair and then to a wheelchair using manual lifting techniques, rather than the required mechanical lift, despite the resident's care plan specifying the use of the lift with two staff present. Video footage confirmed that the mechanical lift was not used during these transfers, and staff statements corroborated that manual lifting occurred. Approximately three hours after the transfer, one of the CNAs reported the resident's injury to an LPN, who was observed on video assessing the resident's arm but failed to report the incident to administration or document the assessment as required by facility policy. The injury, a comminuted fracture of the right humerus, was not formally identified until the following day when another CNA noticed swelling and bruising and reported it to a different nurse, who then initiated appropriate medical evaluation. The delay in reporting and assessment resulted in a delay in diagnosis and treatment of the resident's injury. Interviews and written statements revealed that the involved staff were aware of the injury and the improper transfer method but chose not to report the incident immediately, with one LPN instructing the CNAs not to disclose the event to avoid disciplinary action. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, suffered actual harm as a result of these failures to adhere to policy and promptly report and document the injury.
Infection Control Deficiencies in Medication and Wound Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during medication administration and pressure ulcer care. Observations revealed that LPN C did not follow proper hand hygiene protocol by using her bare wet hand to turn off the faucet after washing her hands. LPN B administered a contaminated medication to a resident after it fell on the bedside table and the resident's chest. Additionally, LPN B did not change gloves or perform hand hygiene between treating clean and soiled pressure ulcers on a resident's knees. Further deficiencies were noted with LPN A, who used a single eyelid wipe for both of a resident's eyes, contrary to the instructions to use one wipe per eye. LPN A also failed to change gloves or perform hand hygiene between administering eye drops and applying cream to the resident's legs and feet. The Director of Nurses confirmed that these actions were not in compliance with the facility's infection control policies, which require the use of a dry paper towel to turn off faucets, discarding contaminated medications, and proper glove and hand hygiene during treatments.
Failure to Maintain Restraint-Free Environment for Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by their policy. The policy, titled 'Restraint Free Environment,' defines physical restraints as any device that restricts freedom of movement and cannot be easily removed by the resident. Despite this, observations revealed that a resident with severe cognitive deficits, as indicated by a BIMS score of 0, was consistently found in a wheelchair with a seat belt that they could not remove. The resident, who has diagnoses including Dementia and Anxiety, was unable to release the seat belt when encouraged to do so by staff. The resident's care plan identified them as high risk for falls due to confusion and unawareness of safety needs, recommending the use of a seatbelt alarm in the wheelchair. However, during an interview, the Assistant Director of Nurses acknowledged that the resident could not release the seat belt on demand, indicating that the device was indeed functioning as a restraint. This oversight demonstrates a failure to adhere to the facility's policy of maintaining a restraint-free environment, as the resident was unable to remove the seat belt independently.
Resident Injury Due to Lift Device Failure
Penalty
Summary
The facility failed to identify, evaluate, and analyze the cause of accident hazards, leading to a significant incident involving a resident. On 12/27/2024, a resident fell from a lift device during a transfer, resulting in a fracture of the left humerus. The incident occurred when the straps of the lift pad broke, causing the resident to fall approximately 4-5 feet to the floor. The resident sustained injuries including a left shoulder fracture and a subdural hematoma. At the time of the incident, the resident was being transferred by a Certified Occupational Therapy Assistant and two Certified Nursing Assistants. The resident involved had a complex medical history, including Parkinson's Disease, Chronic Obstructive Pulmonary Disease, Heart Failure, and Dementia. The resident was chairbound and had a history of intermittent confusion. Despite these conditions, the facility's Fall Risk Evaluation did not indicate any falls in the past three months, and the resident's fall risk score was 11.0. The incident note detailed that the resident was found lying face down on the floor with complaints of pain and altered mental status, and was subsequently transported to the hospital for evaluation and treatment. Interviews with staff revealed that the lift pad used during the transfer had broken straps, which were supposed to be checked for fraying before use. The facility's policy required the resident environment to be free of accident hazards and for staff to implement interventions to reduce risks. However, the facility did not contact the manufacturer about the broken sling, which was reportedly within its usage timeframe. The facility also failed to investigate the cause of the sling failure to prevent future incidents.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and services for an indwelling urinary catheter for a resident. The facility's policy required catheter care to be performed every shift and as needed, but the nursing staff did not obtain a physician's order for the catheter. The resident, who was admitted with diagnoses including pneumonia, diabetes, lymphedema, and a stage 2 pressure ulcer, was cognitively intact as indicated by a Brief Interview for Mental Status score of 15. The care plan for the resident did not include all necessary catheter care related to the indwelling Foley catheter. An observation revealed the resident sitting in a wheelchair with urine draining into a catheter bedside bag. The Director of Nursing confirmed that the resident should have had an order and a care plan for the indwelling catheter care.
Failure in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide adequate dialysis care and communication for a resident requiring such services. The facility's policy on hemodialysis mandates communication with the dialysis center and monitoring of the dialysis site for signs of infection. However, the facility did not document the monitoring of the resident's vascular access site on several occasions, specifically on 2/24/2025, 3/7/2025, 3/11/2025, and 3/14/2025. Additionally, there was a lack of documented communication with the dialysis clinic regarding the resident's care, as confirmed by interviews with the LPN and the Director of Nursing. The resident involved was admitted with multiple diagnoses, including Stage 5 Kidney Disease, Renal Dialysis, Bipolar Disorder, Diabetes Mellitus, Hypertension, and Atrial Fibrillation. The resident was severely cognitively impaired, as indicated by a BIMS score of 00. Despite having physician orders for dialysis three times a week, the facility did not consistently document the necessary monitoring and communication required for the resident's dialysis care, leading to a deficiency in the standard of care provided.
Inaccurate Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the accuracy of its posted nurse staffing information for 24 out of 33 days during the survey period. Specifically, the Daily Staffing Posting lacked Registered Nurse (RN) hours on multiple dates, including 2/13/2025, 2/14/2025, 2/17/2025, 2/19/2025, 2/20/2025, 2/21/2025, 2/24/2025, 2/25/2025, 2/26/2025, 2/27/2025, 2/28/2025, 3/3/2025, 3/4/2025, 3/5/2025, 3/6/2025, 3/7/2025, 3/8/2025, 3/9/2025, 3/10/2025, 3/11/2025, 3/12/2025, 3/13/2025, 3/14/2025, and 3/19/2025. An observation on 3/19/2025 at 9:00 AM confirmed that the staffing posting for that day was blank for RN total hours. During an interview on the same day, the Administrator acknowledged that the Daily Staff Posting should be completed accurately and that RN hours should not be left blank.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure that medications were administered with a medication error rate of less than 5%, resulting in an observed error rate of 8%. This deficiency involved two nurses, LPN B and LPN C, who were responsible for administering medications. In one instance, LPN C administered two different eye medications to a resident with glaucoma without waiting the recommended five minutes between applications, as specified in the facility's policy and the manufacturer's instructions. This resulted in a medication error during the administration process. Additionally, LPN B failed to administer a prescribed multiple vitamin tablet to another resident during the morning medication round. The resident, who had a history of cerebral infarction, hemiplegia, hemiparesis, dementia, and osteoarthritis, did not receive the vitamin as ordered by the physician. The Director of Nursing confirmed that the vitamin should have been administered according to the physician's orders, highlighting a lapse in adherence to medication administration protocols.
Latest citations in Tennessee
Surveyors found that staff did not follow the facility’s infection prevention policies, including Enhanced Barrier Precautions (EBP), hand hygiene, and urinary catheter management. A respiratory therapist performed trach care and suctioning for two residents with tracheostomies without donning required gowns or masks, placed supplies and an inner cannula on the resident’s abdomen and linens, and left a room wearing contaminated gloves. An RN administered meds via a feeding tube for a resident with a gastrostomy, then performed eyelid scrubs without changing gloves or performing hand hygiene between routes of care and without using a gown despite EBP signage. CNAs delivered and set up lunch trays for three residents who required at least some assistance with hygiene or meals but did not offer hand hygiene before eating, contrary to policy. In addition, a resident with a urinary catheter was observed in bed with the drainage bag lying on the floor, rather than suspended from the bed as confirmed by nursing staff and the IP.
Administration allowed an unqualified individual to be hired and work as an LPN by failing to verify licensure and reconcile name discrepancies across hiring documents. The individual’s I-9, birth certificate, and out-of-state driver’s license reflected one last name, while the TN LPN license verification on file belonged to a different nurse with the same first name but a different last name. Abuse registry checks were completed under both names, but no national background check or documentation explaining the differing names was present. The person was offered a temporary/contract LPN position, worked multiple shifts, and had conflicting separation notices, with no documentation of a formal rehire. The HR Director confirmed there was no hiring policy and that the individual worked onsite as an LPN before being terminated for failure to attend or complete training.
Administration failed to ensure nursing services were provided by qualified personnel when an unlicensed individual was hired and allowed to work as an RN and Unit Manager using another nurse’s license. Pre-employment documents for this staff member contained inconsistent SSNs and birth dates across the application, background check, W-4, and I-9, and the background report noted the SSN could not be validated. No abuse registry check or RN license verification was completed before hire, and a later license verification showed the last name on the RN license did not match the individual’s last name. The imposter, a walk-in applicant without a resume, worked multiple shifts providing nursing services before being separated as a voluntary termination, and facility staff did not question the documented discrepancies.
Administration allowed an unlicensed individual to be hired twice and function as an LPN using another LPN’s Tennessee license. During the first hire, conflicting SSNs appeared on the application and tax forms, the I‑9 identified the imposter by her own name and out‑of‑state driver’s license, and the license verification was for a different nurse with only the same first name; no Tennessee Abuse Registry check was documented, and the imposter worked multiple shifts before resigning. During the second hire, a different SSN was used, no I‑9 or supporting identity documents were on file, and the same other nurse’s license was again used for verification; the imposter worked several days before resigning. The Administrator reported that the same resume was used for both hires and that the facility had no formal hiring policy, only a checklist.
Administration failed to ensure nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s license. The facility’s own employment policy requiring HR completion of I-9 Section 2, consistent SSN use, and verification of license and abuse registry status was not followed. The imposter’s application and background check contained conflicting SSNs, names, and birthdates, and the I-9 was not signed by HR. An abuse registry check was run only on one SSN, and discrepancies were not investigated. Time records showed the imposter worked several shifts and had patient access, while leadership later confirmed she remained on the books until being treated as a voluntary termination for not picking up shifts.
Administration failed to ensure nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN under another nurse’s license. Facility records showed multiple unexplained discrepancies in the individual’s name, SSN, and birthdate across the background check, I-9, W-4, Consumer Information Sheet, and separation notice, and the I-9 was never completed or signed by facility staff. Time records confirmed the imposter worked several shifts as an RN before being terminated for no call/no show, and an abuse registry check was not completed until long after termination. The facility did not produce hiring policies or documentation that anyone questioned the conflicting identification information before or during this person’s employment.
Staff failed to honor a resident’s right to refuse care when CNAs proceeded with a scheduled shower despite the resident verbally declining. The resident, who had severe dementia with agitation and was dependent on staff for bathing, had a care plan directing staff to discuss objections, inform of risks, offer choices, and accept refusals. Instead, after the resident said they did not want a shower, one CNA pulled off the covers, and the CNAs placed the resident in a shower chair and continued with the shower because it was the resident’s assigned shower day, contrary to facility policy and the care plan.
A resident with severe cognitive impairment and multiple comorbidities was admitted for rehab and had clearly documented full code status in the face sheet, care plan, and physician orders. During the night, the resident was last observed awake and later found unresponsive with no heart sounds, pulse, or respirations. Staff initiated CPR and continued until the resident was pronounced deceased, but the record contained no evidence that EMS/911 was contacted or that an AED was obtained or used, despite facility policy and leadership expectations that full code residents receive CPR with 911 activation and AED use, and despite the presence of two AEDs in the facility.
A resident with severe cognitive impairment, type 2 DM, CKD, and a history of falls had physician orders for blood glucose checks before meals and at bedtime and for sliding scale insulin aspart four times daily. Facility policy required verification of insulin orders, blood glucose monitoring per orders, and documentation of results and doses. However, after an NP attempted to edit the sliding scale order in the EHR, the order remained unsigned and inactive in the queue, preventing it from appearing on the MAR. Nursing staff did not identify that the insulin order was missing, resulting in multiple missed blood glucose checks and insulin doses over several days, despite the resident’s care plan directing staff to follow physician orders for diabetes management.
The facility failed to maintain a clean and sanitary environment in multiple resident rooms and bathrooms, despite policies requiring routine cleaning and disinfection. Observations over several days found a motorized wheelchair and another wheelchair with attached cushion soiled with dried, multi-colored debris. Several resident bathrooms had unclean conditions, including a trash can without a liner and with dried brown residue, toilets with dried yellow residue on the seats, and yellow/orange or brown substances around the bases of multiple toilets. During an on-site check, the Administrator confirmed that the residue around one toilet could be wiped away and that the area was not clean.
Failure to Follow EBP, Hand Hygiene, and Catheter Practices During Respiratory, Enteral, and Daily Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies, including Enhanced Barrier Precautions (EBP), hand hygiene, and urinary catheter management. The facility’s EBP policy required staff to perform hand hygiene, review EBP signage, and don gown and gloves prior to high-contact resident care activities such as tracheostomy care, suctioning, and device care, then remove PPE and perform hand hygiene before leaving the resident’s room. For Resident #1, who had epilepsy, acute on chronic respiratory failure, a tracheostomy, and ventilator dependence, a respiratory therapist entered the room where EBP signage was posted, used pocket hand sanitizer, and donned gloves but did not don a gown or mask. The therapist placed clean gauze and used split gauze directly on the resident’s abdomen, allowed the tracheostomy inner cannula to roll from the abdomen onto the linens, and then left the room carrying a box while still wearing the same contaminated gloves, only discarding them later at the respiratory therapy cart. The therapist acknowledged not setting up supplies appropriately, not discarding gloves and performing hand hygiene before leaving the room, and not following EBP, stating she believed EBP was only required for residents with an active infection. For Resident #8, who had traumatic brain injury, quadriplegia, acute respiratory failure, and a tracheostomy, the same respiratory therapist again entered a room with EBP signage and donned gloves but no gown or mask before performing tracheal suctioning using an in-line suction catheter. The resident had reflex coughing during suctioning. After completing suctioning, the therapist discarded gloves and used pocket hand sanitizer but again did not follow the full EBP requirements. The infection preventionist later confirmed that EBP was required for high-contact care such as tracheal care and suctioning, and that gloves should be discarded before leaving the room with hand hygiene performed each time gloves are removed. The facility also failed to follow EBP and hand hygiene practices during medication administration for Resident #22, who had chronic respiratory failure, quadriplegia, tracheostomy status, and gastrostomy status, and who had long- and short-term memory deficits with severely impaired decision-making. A registered nurse entered the resident’s room, where EBP signage was posted, donned gloves but not a gown, and administered medications via the gastrostomy tube using a piston syringe, flushing with water as ordered. With the same used gloves still on, the nurse rinsed the piston syringe in the room sink, set it on paper towels to dry, and then performed OcuSoft eyelid scrubs to both eyes without changing gloves or performing hand hygiene between the different routes of care. The nurse confirmed she did not don a gown and did not perform hand hygiene or change gloves between the feeding tube medication administration and the eye care, and the infection preventionist confirmed that EBP and hand hygiene with glove changes were expected between administering medications by different routes. Additional deficiencies were identified in hand hygiene assistance before meals and urinary catheter management. The facility’s resident handwashing policy required staff to offer hand hygiene before meals. Resident #47, who had acute and chronic respiratory failure, epilepsy, atrial fibrillation, and chronic pulmonary edema and was dependent for hygiene and feeding assistance, received a lunch tray from a CNA who set up the tray and left without offering hand hygiene assistance. Resident #31, with COPD, acute and chronic respiratory failure, morbid obesity, and a care plan indicating partial to moderate assistance with hygiene, also had a lunch tray delivered and set up by a CNA who exited without offering hand hygiene. Resident #66, with COPD, chronic respiratory failure, generalized muscle weakness, and substantial to maximal ADL needs including meal assistance, likewise had a lunch tray delivered and set up without being offered hand hygiene. One CNA acknowledged residents were to be offered hand hygiene before meals, and another stated she had not offered hand hygiene unless residents mentioned it. The infection preventionist confirmed staff were expected to offer hand hygiene assistance to all residents prior to meals. The facility further failed to maintain proper urinary catheter bag positioning for Resident #15, who had chronic osteomyelitis, depression, anxiety, paraplegia, and required assistance with ADLs, including urinary catheter care per orders and protocol. During observation, the resident was in bed with the urinary catheter drainage bag lying on the floor beside the bed. A licensed practical nurse confirmed the catheter bag should be hung from the bed, and the infection preventionist confirmed catheter bags were to be suspended off the ground to prevent infection. These observations demonstrated non-adherence to the facility’s infection prevention and control practices related to EBP, hand hygiene, and catheter management across multiple residents and care situations.
Imposter Hired and Employed as LPN Without Proper License Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an LPN using another nurse’s Tennessee license. Personnel file review showed that the individual, referred to as Imposter Nurse A, had an I-9 form completed with her legal first and last name, supported by a birth certificate and an out-of-state driver’s license, and a Tennessee Criminal History Record Request indicating no Tennessee criminal history under that name. However, the nursing license verification in the file was for a different person, an LPN with the same first name but a different last name (LPN C). Two Tennessee Abuse Registry checks were present, one under LPN C’s name and one under Imposter Nurse A’s name, but there was no documentation explaining or reconciling the name discrepancies between the I-9, the license verification, and other employment documents. There was also no national background check in the personnel file. The facility issued an offer letter to Imposter Nurse A for a temporary/contract LPN position, and time sheets showed she worked multiple shifts on several dates. Two separation notices documented voluntary separation without notice, with differing last days worked, and there was no paperwork provided to explain her apparent rehire after the first termination. During interview, the Human Resource Director acknowledged there was no hiring policy, confirmed that Imposter Nurse A worked onsite as an LPN, and stated she was terminated for failure to attend or complete training and for failure to come in as needed. No information was provided to surveyors showing any cross-check or investigation of the inconsistent names across the employment application, I-9 form, and nursing license verification, resulting in the facility employing an unqualified person in an LPN role.
Imposter RN Hired and Allowed to Function Without Proper Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s Tennessee license. Facility policy titled “Abuse Program Policy” required pre-employment screening, including obtaining a copy of the state license for licensed positions and completing a criminal background check per state statute. The application for employment for the imposter nurse contained a scratched-out Social Security Number (SSN) with a different SSN written above that did not match the SSN on the I-9 form, and the birth date on the application also did not match the I-9. The background screening report showed an SSN and birth date that did not match the I-9 and included a note stating “UNABLE TO VALIDATE SSN.” A W-4 form contained an SSN that did not match the background check. The I-9 form listed the imposter’s legal first and last name, with a Social Security card and valid Tennessee driver’s license, but the birth date on the I-9 differed from the birth date on the background check. Review of the personnel file revealed no evidence that an abuse registry check was completed prior to hire, and there was no evidence that a license verification was done before the imposter nurse’s start date. Time cards showed the imposter worked multiple days in February and March as a Unit Manager. A later QuickConfirm license verification showed that the last name on the validated RN license did not match the imposter’s last name. Interviews with the DON, HR representative, and Administrator confirmed that the imposter was a walk-in applicant who did not provide a resume, that in-house HR was responsible for ordering background checks with corporate as backup, and that the imposter worked in the facility as a Unit Manager and was only separated as a voluntary termination for inability to uphold weekend schedule obligations. There was no evidence that the facility questioned the discrepancies in names, birth dates, or SSNs on the pre-employment documents, resulting in the employment of an unqualified person to render nursing services as an RN.
Imposter Nurse Hired Twice and Allowed to Function as LPN Without Proper Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and allowed to function as an LPN on two separate occasions using another nurse’s Tennessee license. For the first hire, the personnel file showed an employment application dated 02/08/2023 with a Social Security Number (SSN) that did not match the SSN on the W‑4 form dated 02/13/2023. The I‑9 form dated 02/13/2023 listed the imposter’s legal first and last name, supported by a birth certificate and an out‑of‑state driver’s license, and the last name on the I‑9 matched the driver’s license. However, the license verification form in the file was for a different individual, an LPN with the same first name but a different last name, and there was no evidence that a Tennessee Abuse Registry check was completed prior to the 02/13/2023 hire date. Time punch records showed the imposter worked multiple shifts in February, March, April, and May 2023 before being terminated on 06/06/2023, with the termination form citing voluntary resignation due to chronic absenteeism and tardiness. For the second hire, the imposter was rehired with a personnel file showing that the SSN on the employment application, W‑4, and background check matched each other but differed from the two SSNs used during the first hire, meaning three different SSNs were used across the two employment periods. There was no I‑9 form or supporting identity documents in the file for the rehire. A license verification form again showed a nursing license in the name of the same LPN whose license had been used previously, with the same first name as the imposter but a different last name and a later expiration date. The background screening report dated 02/13/2024 used the SSN from the employee application, which did not match the SSN previously submitted on the I‑9 form from the first hire. Time punch data showed the imposter worked several days in May 2024 before a termination dated 06/24/2024, which documented voluntary resignation after failing to provide a schedule and not returning after orientation. In an interview, the Administrator stated the facility used the same resume for both hires and that the facility did not have a hiring policy, only a checklist.
Imposter RN Hired and Allowed to Work Without Proper License Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s Tennessee RN license. The facility’s Employment policy required the HR Director to complete Section 2 of the I-9, conduct background investigations, and verify licenses and abuse registry status using the applicant’s registration or Social Security number. Review of the imposter’s employment application showed a Social Security number scratched out and replaced with another number that did not match the SSN used on the background check. The background check listed both the imposter’s name and the legitimate RN’s name, and it showed the legitimate RN’s license number. The birthdate on the I-9 did not match the birthdate on the background check, and Section 2 of the I-9 was not signed by the HR Director as required by policy. Further review showed that an abuse registry search was completed using the SSN from the Social Security card submitted with the I-9, but no search was conducted using the SSN listed on the background check. The separation notice for the imposter listed her real first and last name with an SSN that again did not match the SSN on the background check, and documented employment from mid-June to late November with the reason for termination as voluntary due to not picking up shifts for over three months. Employee time entries showed the imposter worked multiple days in June and one day in July. The DON confirmed that the imposter used an online artificial intelligence website for charting and stated the imposter had access to patients for one day in July. The Administrator confirmed the imposter was considered employed during the stated period and was not formally fired or documented as having quit. There was no evidence that the facility questioned the discrepancies in names, birthdates, or Social Security numbers on the pre-employment documents, resulting in the employment of an unqualified person as an RN.
Imposter RN Hired and Allowed to Work Despite Multiple Identification Discrepancies
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s Tennessee license. Personnel file and document review showed multiple inconsistencies in the imposter nurse’s identifying information that were not questioned by the facility. The background check dated 06/14/2024 used a Social Security Number (SSN) that did not match the SSN on the Social Security card submitted. The I-9 form dated 06/15/2024 listed the imposter’s legal first and last name, with a copy of her Social Security card and a valid Tennessee driver’s license, but the SSN on the I-9 did not match the SSN on the Social Security card. The I-9 form was not completed, signed, or dated by any facility representative. Time punch data showed the imposter nurse worked multiple days in June and July 2024. A separation notice dated 07/31/2024 listed the imposter’s real first and last name with an SSN that did not match the SSN on the I-9 form, and documented employment dates from 06/12/2024 to 07/31/2024 with termination for no call/no show. An undated Consumer Information Sheet listed the imposter’s first and last name with the legitimate RN’s last name as her middle name, a birth year that did not match the I-9, and an SSN that did not match the SSN on the W-4 form or the separation notice. The abuse registry check for the imposter was not completed until 08/04/2025, after termination. The facility did not provide any hiring policies and there was no evidence that staff questioned the discrepancies in names, birth dates, or SSNs on the pre-employment forms, resulting in the employment of an unqualified person as an RN.
Failure to Honor Resident’s Refusal of Shower and Right to Self-Determination
Penalty
Summary
The deficiency involves staff failure to honor a resident’s right to self-determination and refusal of treatment, specifically related to bathing. Facility policy on Resident Rights and Responsibilities states that residents have the right to refuse treatment and to be informed of the medical consequences of such refusal, and to exercise their rights without discrimination or reprisal. Resident #31, admitted in late 2023, had severe dementia with agitation, a BIMS score of 3 indicating severe cognitive impairment, and was dependent on staff for showering and personal hygiene. The resident’s care plan identified behavior problems and resistance to care related to dementia, knowledge deficit, denial of illness and risk factors, and mental/emotional illness, with interventions directing staff to discuss objections and fears, inform the resident of risks of non-compliance, offer choices, and accept and respect the resident’s right to refuse care. Despite these policies and care plan interventions, staff proceeded with a shower after the resident refused. A CNA assigned to the resident reported that the resident had refused a shower, and another CNA responded that it was the resident’s shower day and that the shower should be provided. According to written statements, when the CNAs entered the room and informed the resident it was shower day, the resident stated, “No I don’t want a shower.” One CNA then told the resident they were getting a shower and pulled the covers off the resident. The CNAs placed the resident in a shower chair and continued with the shower despite the expressed refusal. During a later interview, the CNA confirmed instructing the other staff member to go ahead and provide the shower because it was the resident’s scheduled shower day, demonstrating that the resident’s right to refuse care and the care plan interventions to respect refusals were not followed.
Failure to Contact EMS and Use AED During CPR for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its CPR and emergency response policy for a resident who was a documented full code. Facility policy required staff to call 911 for resident emergencies, obtain and use an AED, and initiate CPR for full code residents unless there was a POST form or other physician order to withhold CPR, or the resident showed American Heart Association (AHA) signs of clinical death. The 2020 AHA Adult Basic Life Support Algorithm directs healthcare providers to activate the emergency response system, obtain an AED, and use it as soon as available when a person has no breathing or only gasping and no pulse. The facility had two AEDs and staff were educated on AED use as part of CPR training. Resident #78 was admitted for rehabilitation and 24-hour skilled nursing care following a hospitalization due to a fall at home and had a medical history including atrial fibrillation with multiple cardioversions, dysphagia, chronic kidney disease, mild cognitive impairment with memory loss, hypertension, UTI, influenza, and type 2 diabetes mellitus. The resident’s profile, care plan, and physician’s orders all documented full code status. A 5-day MDS showed a BIMS score of 4, indicating severe cognitive impairment. On the evening prior to the event, an RN documented that the resident was sitting in a wheelchair watching television at 8:20 PM, was assisted to the bathroom at 10:00 PM, and was checked again at 12:00 AM. At approximately 2:00 AM, a CNA found the resident unresponsive and notified the RN, who assessed the resident and documented no heart sounds, pulse, or respirations. Staff initiated CPR and continued efforts until the RN pronounced the resident deceased at 2:45 AM. There was no documentation in the medical record that EMS/911 was contacted or that an AED was used during the resuscitation attempt, despite facility policy and the expectations stated by the DON, LPN, NP, and Medical Director that staff should call 911, obtain and use an AED, and continue CPR until EMS arrival for a full code resident. An email from the local fire department indicated there were no EMS reports for the resident on the date in question, and the DON stated she had no evidence to verify that EMS was contacted and no AED log to show whether an AED was used. The Administrator stated she expected staff to follow the CPR policy and properly document all care and services provided, but the record lacked evidence of EMS notification or AED utilization for this full code resident.
Failure to Activate and Follow Sliding Scale Insulin and Blood Glucose Orders
Penalty
Summary
The deficiency involves the facility’s failure to activate and carry out physician orders for blood glucose monitoring and sliding scale insulin for a resident with type 2 diabetes. Facility policy on insulin administration required verification that insulin type, dosage, strength, and method of administration corresponded with the physician’s order, checking blood glucose per physician order or facility protocol, and documenting blood glucose results and insulin doses. The resident’s care plan for diabetes directed staff to check blood sugar levels via fingerstick per physician orders and to administer medications per physician orders. The resident was admitted for rehabilitation and 24-hour skilled nursing care following a hospitalization due to a fall at home and had a medical history that included chronic kidney disease and type 2 diabetes mellitus. A 5-day MDS showed severe cognitive impairment with a BIMS score of 4 and an active diagnosis of type 2 diabetes, with insulin injections received. Physician orders directed staff to check the resident’s blood sugar before meals and at bedtime, four times a day, and to administer insulin aspart via a sliding scale four times a day. These orders were in place with a specified stop date and then renewed. Despite these orders, the medication record for the resident showed no documentation of blood sugar levels or administration of insulin aspart at multiple ordered times over several days. A family member reported concern that the resident’s blood sugar levels had not been checked for the past couple of days and that the resident was not on a short-acting insulin. A medication error report later identified that the NP had updated the sliding scale insulin order, but the update was not signed and remained in the unsigned order queue, leaving the insulin aspart order inactive on the MAR. As a result, nursing staff could not see the updated order and missed multiple doses of insulin aspart. The NP stated that she had intended to edit, not discontinue, the sliding scale order, but the electronic medical record required her to unsign the order to edit it, and she failed to reactivate it. The DON stated that nursing staff failed to identify that the insulin aspart order was missing and remained in the queue awaiting reactivation, and the Administrator stated that her expectation was for staff to follow company policy and for the DON or designee to verify that all active orders were visible for nurses when a plan of correction for missing insulin doses had been implemented. A physician statement documented that the resident had uncontrolled type 2 diabetes mellitus, CKD stage III, and hyperlipidemia, and that the resident received sliding scale insulin on one day but did not receive any sliding scale insulin on the following two days. The physician noted that the resident’s blood glucose reached a maximum level of 343 mg/dL during this period and that the sliding scale insulin order was later replaced and resumed. These findings collectively show that the facility did not provide treatment and care according to physician orders and the resident’s care plan for diabetes management, due to the failure to activate and monitor the sliding scale insulin and blood glucose orders in the electronic system and to recognize and correct the missing active order on the MAR.
Failure to Maintain Clean and Sanitary Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean and sanitary environment in multiple resident rooms and bathrooms, contrary to its own policies on routine bathroom cleaning and routine cleaning and disinfection. The facility’s policies, dated 6/2025, required providing a clean and sanitary environment, cleaning the entire toilet including the handle and underside of the flush rim with disinfectant and appropriate contact time, and reporting damaged items in need of repair. Observations conducted on several days showed that in one room, a motorized wheelchair had dried debris on the cushion, arms, and a large amount of multi-colored debris on the undercarriage. In another room, a wheelchair with a fabric heel protector cushion used as an armrest was spattered with small to pea-sized unknown multi-colored particles. Additional observations revealed that several resident bathrooms were not maintained in a sanitary condition. One bathroom had a trash can without a bag and with a dried brown substance on the outside, rim, and inside of the can, as well as a toilet seat with two areas of dried yellow residue and a yellow/orange substance around the base of the toilet. Other bathrooms in different rooms had yellow/orange or brown residue around or at the front base of the toilets. During an observation and interview in one of the bathrooms, the Administrator initially suggested the substance around the toilets might be related to the wax ring, but after wiping a small area with a wet wipe, the yellow/orange substance was easily removed, and the Administrator confirmed the area around the toilet was not clean.
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