Ocoee Transitional Care Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Maryville, Tennessee.
- Location
- 2320 East Lamar Alexander Pkwy, Maryville, Tennessee 37804
- CMS Provider Number
- 445404
- Inspections on file
- 17
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Ocoee Transitional Care Center Llc during CMS and state inspections, most recent first.
A resident admitted with UTI, Enterococcus faecalis bacteremia, and presumptive infective endocarditis had hospital and ID orders for IV ampicillin 2 g q4h to continue through a January stop date, but the Admission Nurse entered an incorrect December stop date into the facility’s system, which was then confirmed by an RN. The care plan and MAR reflected this erroneous end date, and IV ampicillin was administered only until mid-month, then stopped, resulting in 59 missed doses before the error was later discovered. A medication occurrence report cited omitted doses due to admission order and chart check errors, and leadership confirmed that staff and pharmacy failed to catch the discrepancy between the electronic order and the written hospital/ID orders.
A resident admitted with UTI, urinary retention, and Enterococcus faecalis bacteremia had hospital infectious disease orders for Ampicillin 2 g IV Q4H through a January stop date. When admission orders were entered into the eMAR (PCC), the admissions nurse transcribed the stop date incorrectly as December instead of January. Although the pharmacy provider received faxed orders with the correct stop date and was contractually responsible for verifying that faxed orders matched PCC entries, its medical records department did not identify the discrepancy. A pharmacist from the pharmacy provider completed a Drug Regimen Review with no recommendations, and a contracted consultant pharmacist performed an admission Medication Regimen Review and documented no irregularities, despite policies requiring thorough review of orders, documentation, and stop dates. As a result, the IV antibiotic was automatically stopped on the incorrect December date, and the resident missed multiple scheduled doses until the error was discovered and the medication was resumed.
A resident admitted with UTI, Enterococcus faecalis bacteremia, sepsis, anemia, and a presumptively infected atrial thrombus had hospital orders for IV ampicillin q4h and ceftriaxone q12h to run concurrently through a specified January stop date. On admission, the ampicillin order was entered into the EHR with an incorrect December stop date, while the ceftriaxone order was entered correctly. The RN Charge Nurse’s verification and a subsequent 24-hour chart check by an LPN did not detect the incorrect ampicillin stop date, and the care plan also reflected the shortened course. As a result, the resident received ampicillin only until the erroneous December stop date and then missed 59 scheduled doses before the error was later discovered, while ceftriaxone continued as ordered.
A resident admitted with UTI, urinary retention, and Enterococcus faecalis bacteremia had an order for IV Ampicillin every 4 hours with a specified stop date. On admission, an RN entered the wrong stop date into the system, and both the confirming RN and an LPN performing the 24-hour chart check failed to detect that the electronic order did not match the written physician order. Although the pharmacy had the correct stop date and continued sending the medication, it accumulated in the med room until another RN noticed the excess supply and discovered that the antibiotic had been stopped early, resulting in 59 missed doses. Despite facility policies requiring prompt QAPI review and process improvement for medication errors, the error was not brought to an ad hoc QAPI meeting or used to initiate a timely PIP, and was instead deferred to a later scheduled QAPI meeting.
Failure to Follow IV Antibiotic Orders Due to Incorrect Stop Date Entry
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for IV antibiotic therapy for one resident admitted with a UTI, urinary retention, Enterococcus faecalis bacteremia, and presumptive infective endocarditis. Hospital discharge documentation and an infectious disease (ID) physician note specified that the resident was to receive ampicillin 2 g IV every 4 hours through a specified January stop date, representing six weeks of therapy after the first negative blood cultures. These written hospital orders, present in the resident’s physical chart, clearly directed continuation of IV ampicillin at that dose and frequency until mid-January. On admission, the Admission Nurse entered the ampicillin order into the facility’s computer system with an incorrect stop date in December instead of the January stop date ordered by the ID physician. The electronic order was entered to run from the admission date with an end date in mid-December, and this incorrect order was confirmed by the RN Charge Nurse later that same day. The comprehensive care plan for antibiotic therapy also reflected the incorrect December stop date. As a result, the Medication Administration Record (MAR) shows that the resident received ampicillin IV every four hours only from the evening of admission through mid-December, at which point the medication was stopped per the erroneous end date. Because of the incorrect stop date and failure to reconcile the electronic order with the hospital discharge and ID orders, the resident did not receive ampicillin from mid-December until the medication was later resumed in late December, resulting in 59 missed doses of IV ampicillin. A Medication Occurrence Report documented this as an omitted dosage error caused by an admission order error and chart check error, noting that the infectious disease orders in the chart had the correct January stop date while the electronic order had the wrong December stop date. The DON confirmed that the Admission Nurse, the RN Charge Nurse, and the pharmacy consultant did not identify the discrepancy at the time of admission, and that the resident’s ampicillin was discontinued earlier than ordered, leading to the lapse in therapy.
Failure of Pharmacy Services and Consultant Pharmacist to Detect Incorrect IV Antibiotic Stop Date
Penalty
Summary
The deficiency involves a failure of the facility’s pharmaceutical services, including both the contracted pharmacy provider and the consultant pharmacist, to identify a transcription error in an IV antibiotic order, resulting in an incorrect stop date and an extended omission of ordered doses. A resident was admitted with diagnoses including UTI, urinary retention, and Enterococcus faecalis bacteremia, and had hospital infectious disease orders for Ampicillin 2 g IV every 4 hours to continue through a specified date in January. The hospital discharge summary and infectious disease note documented Ampicillin 2 g IV every 4 hours with a stop date of January 13. The facility faxed the admission orders to the pharmacy provider, and the order was entered into the facility’s electronic system (PCC) on the day of admission as Ampicillin Sodium Solution 2 g IV every 4 hours, but with an incorrect stop date of December 13 instead of January 13. The order was confirmed in the system later that same day. According to facility policy, the consultant pharmacist is responsible for providing consultation on all aspects of pharmacy services, including helping the facility develop processes for receiving and transcribing medication orders, and for performing a Medication Regimen Review (MRR) for every resident upon admission and at least monthly. The MRR is to include a thorough review of the medical record to prevent, identify, report, and resolve medication-related problems and errors, including omissions of ordered medications and documentation-related errors. The pharmaceutical services agreement with the pharmacy provider also requires that a licensed pharmacist review each resident’s drug regimen, including the medical chart, and report any irregularities to the attending physician, medical director, and DON. The agreement further states that the pharmacy will use an electronic system (PCC) to manage orders and MARs and that the pharmacy’s medical records department is responsible for ensuring that faxed orders match what is entered into PCC. Despite these requirements, multiple review processes failed to detect the incorrect stop date. The pharmacy provider received the faxed admission orders on the day of admission, which correctly showed Ampicillin 2 g IV every 4 hours with a stop date of January 13, but the facility-entered order in PCC reflected a stop date of December 13. A pharmacist from the pharmacy provider performed a Drug Regimen Review on the day of admission and documented that the medications were reviewed with no recommendations. The consultant pharmacist completed an admission Pharmacy Drug Regimen Review three days later and also documented no recommendations or irregularities. The consultant pharmacist later stated that she reviews new admission medications to ensure physician orders match what is entered in PCC and that stop dates are part of this review, and acknowledged she should have identified an incorrect stop date. The pharmacy provider’s Director of Operations confirmed that the medical records department’s verification, completed three days after admission, should have identified the discrepancy between the faxed order’s January stop date and the December stop date entered in PCC but did not. As a result, the MAR shows the resident received Ampicillin IV every four hours from the evening of admission through December 13, when the medication stopped per the incorrect stop date, and the resident then missed 59 doses between December 13 and December 24, when the error was finally identified and the medication was resumed. Interviews further clarified the sequence of events and the roles of involved staff. The DON stated that the admissions nurse entered the Ampicillin order with the incorrect December stop date, causing the medication to stop in error on that date. The DON confirmed that the error was not identified until December 24, at which time an order was obtained to resume the medication, and that the resident missed doses every four hours during the gap period. The Medication Occurrence Report documented the error as an omitted dosage due to an admission order error and chart check error, specifying that the wrong stop date was entered on admission and that infectious disease orders present in the record had the correct January stop date. The pharmacy provider’s Director of Operations confirmed that the faxed order to the pharmacy showed the correct January stop date, that the facility had entered a December stop date into PCC, and that the pharmacy’s medical records verification process should have detected and reported this discrepancy but did not. These combined failures by the facility’s pharmacy services and consultant pharmacist to identify and correct the transcription discrepancy led to the prolonged interruption of the resident’s ordered IV antibiotic therapy.
Omission of 59 IV Ampicillin Doses Due to Incorrect Stop Date Entry and Missed Chart Checks
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when 59 ordered doses of IV ampicillin were omitted. The resident was admitted from the hospital with diagnoses including UTI, Enterococcus faecalis bacteremia, sepsis secondary to UTI, anemia, and a presumptively infected left atrial thrombus. Hospital infectious disease documentation and the discharge summary specified that the resident was to receive ampicillin 2 g IV every 4 hours and ceftriaxone (Rocephin) 2 g IV every 12 hours through a specific January stop date, representing six weeks of therapy after the first negative blood cultures. These written hospital orders, present in the resident’s physical chart, clearly indicated that both IV antibiotics were to continue concurrently through mid-January. On admission, the Admission Nurse entered the IV antibiotic orders into the facility’s electronic system (PCC). While the ceftriaxone order was entered with the correct stop date, the ampicillin order was entered with an incorrect stop date in December instead of the January date ordered by the infectious disease physician. The RN Charge Nurse confirmed the admission orders in the electronic system against the physical hospital orders but did not identify the discrepancy in the ampicillin stop date. A 24-hour chart check was then completed by an LPN, who also failed to detect that the ampicillin stop date in the computer did not match the physician’s written orders. The comprehensive care plan that was initiated likewise reflected the incorrect, shortened ampicillin date range. As a result of the incorrect stop date and the missed verification opportunities, the resident received IV ampicillin every four hours only from the evening of admission through the early evening of the erroneous December stop date. After that point, the ampicillin was automatically discontinued in the system, and the resident did not receive any further doses until the medication was later restarted. Review of the MAR showed that the resident missed 59 doses of IV ampicillin between the erroneous discontinuation date and the date the order was resumed, while ceftriaxone continued to be administered as ordered. The medication occurrence report identified the error as an omitted dosage caused by an admission order error and chart check error, and the DON confirmed that the facility’s medication verification processes were not followed, resulting in the resident not receiving ampicillin as ordered during that period.
Failure to Identify Significant IV Antibiotic Omission and Initiate Timely QAPI PIP
Penalty
Summary
The deficiency involves the facility’s failure to timely identify and address a significant medication error involving omitted doses of IV antibiotics for Resident #1 and to initiate a Process Improvement Project (PIP) through its QAPI program. Facility policies on adverse consequences and medication errors, administering medications, medication regimen review (MRR), and QAPI require that medication errors, including omissions, be promptly identified, reported, analyzed by the QAPI committee, and used to drive process improvements. Despite these policies, the facility did not recognize and elevate a serious omission of ordered IV Ampicillin as a quality deficiency in a timely manner. Resident #1 was admitted with diagnoses including UTI, urinary retention, and Enterococcus faecalis bacteremia, and had an order for Ampicillin IV 2 g every 4 hours with a stop date of 1/13/2026 per infectious disease orders. On admission, the Admissions Nurse entered the stop date incorrectly as 12/13/2025 instead of 1/13/2026. The RN Charge Nurse, responsible for confirming the order, failed to identify that the stop date entered into the computer system did not match the written physician order. LPN A, who performed the 24-hour chart check, also failed to detect the incorrect stop date, even though the procedure required verifying that the written physician’s order matched what was entered into the electronic system. The pharmacy provider entered the correct stop date of 1/13/2026 in its system and continued sending Ampicillin to the facility, resulting in an accumulation of the medication in the medication room. The error was not identified until RN A noticed an abundance of Ampicillin on 12/24/2025 and performed a chart check, revealing that the medication had been stopped 11 days earlier than ordered. This led to 59 missed doses of IV Ampicillin for Resident #1. Interviews with the ADON, Interim Administrator, and DON confirmed that the facility’s medication verification processes were not followed, that the error was considered significant, and that no ad hoc QAPI meeting or PIP had been initiated prior to the next scheduled QAPI meeting, despite the facility’s policies requiring QAPI involvement in reviewing medication errors and implementing process improvements.
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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