Okeena Health And Rehabilitation Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Dyersburg, Tennessee.
- Location
- 1900 Parr Avenue, Dyersburg, Tennessee 38024
- CMS Provider Number
- 445446
- Inspections on file
- 13
- Latest survey
- January 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Okeena Health And Rehabilitation Center Llc during CMS and state inspections, most recent first.
The facility failed to complete timely nutritional assessments for two residents due to the absence of a registered dietitian. The assessments, required within 72 hours of admission, were delayed due to the resignation of the former dietitian and the late start of a new remote dietitian. The Director of Dietary, who was uncertified, confirmed the lack of supervision during this period.
The facility failed to maintain sanitary conditions for an ice machine, as it was observed with a white chalky substance dripping down its sides. The Dietary Director stated that an outside company was responsible for cleaning, but she was accountable for the machine. The Administrator confirmed the machine should be clean.
The facility failed to follow infection control protocols, with staff not properly removing PPE, disinfecting equipment, or performing hand hygiene. These lapses involved residents with conditions like COVID-19 and influenza, and were confirmed by the DON and ICP.
The facility failed to maintain resident dignity during meal assistance, as staff stood over a resident to feed them and used informal language, such as "girl," when addressing residents. Additionally, a CNA referred to residents as "feeders" in the hallway, contrary to the facility's policy on promoting resident dignity.
The facility failed to ensure a clean and sanitary environment in shared bathrooms, with personal hygiene items found unlabeled and uncontained. Residents with various medical conditions, including cognitive impairments and dependencies on staff for ADLs, were affected. The Director of Nursing confirmed that facility policy required these items to be stored properly, highlighting a systemic issue in maintaining sanitary conditions.
The facility failed to update care plans for residents with pressure ulcers, COVID-19, and influenza. A resident with pressure ulcers did not have a care plan reflecting prevention and treatment. Another resident tested positive for COVID-19, but the care plan was updated seven days later. A resident with influenza was in isolation, but the care plan was not revised. Lastly, a resident with COVID-19 was in transmission-based precautions, but the care plan was not updated. The facility did not follow its policy to revise care plans upon status changes.
A resident's pressure wounds were misclassified as non-pressure vascular wounds, contrary to the facility's policy requiring accurate staging and care planning. Observations and interviews confirmed the wounds were deep tissue injuries, not vascular, leading to improper care.
The facility failed to ensure a safe environment by leaving hazardous items accessible in resident rooms. A resident with cognitive impairment had air fresheners and body sprays unsecured, while another resident had an unattended razor in the bathroom. Staff confirmed these items should have been secured to prevent resident access.
The facility failed to post complete daily staffing information, omitting the scheduled total number of FTEs and their hours, as well as the actual hours worked by licensed and unlicensed staff for 31 days. The Scheduler and DON confirmed the postings were incomplete and should have included all necessary details, including changes due to call-ins.
The facility failed to properly document and manage narcotic medications, leading to discrepancies in narcotic counts and improper documentation of medication administration and destruction. For a resident, Hydrocodone/APAP administration was not documented correctly, and doses were not accounted for. Another resident's Gabapentin count showed discrepancies between the quantity left and destroyed. Additionally, a third resident's Lorazepam administration was improperly documented, with no record of medication being wasted. These issues were not identified or resolved by staff during narcotic counts or drug destruction.
A facility failed to secure medications properly when a Wound Nurse left a treatment cart unlocked and unattended. The DON confirmed the presence of medications on the cart, which included various wound treatment medications. This action violated the facility's policy requiring all drugs to be stored in locked compartments accessible only to authorized personnel.
Delayed Nutritional Assessments Due to Staffing Issues
Penalty
Summary
The facility failed to ensure comprehensive nutritional assessments were completed timely by a dietitian for two residents reviewed for new admissions. According to the facility's policy, a comprehensive nutritional assessment should be completed by a dietitian within 72 hours of admission. However, for Resident #256, who was admitted with diagnoses including Diabetes, Chronic Obstructive Pulmonary Disease, and Dependence on Renal Dialysis, the assessment was not completed until six days after admission. Similarly, Resident #259, who was readmitted with diagnoses including Protein-Calorie Malnutrition, Toxic Encephalopathy, and Respiratory Failure, did not receive a comprehensive nutritional assessment until the eighth day after readmission. The deficiency was attributed to the absence of a registered dietitian following the resignation of the former dietitian after Christmas. The Director of Dietary, who was not certified, confirmed that there was no supervision in place during this period. The Director of Nursing confirmed that the new dietitian, working remotely, only started on January 13, 2025, which contributed to the delay in completing the nutritional assessments for the residents in question.
Unsanitary Ice Machine Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions for food storage, preparation, and service, as evidenced by a dirty ice machine. The facility's policy on ice machines and portable ice carts, dated December 1, 2024, mandates that ice machines be cleaned and maintained to prevent microbial contamination. However, during an interview, the Dietary Director stated that the cleaning and maintenance of the ice machine were contracted to an outside company, but she was responsible for the ice machine within the facility. Observations of the ice machine in the Activity Room revealed a white chalky substance dripping down the sides of the machine and the cart it was on. The Administrator confirmed that the ice machine should be clean and free of any such substances.
Infection Control Lapses in PPE Removal and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols, as evidenced by multiple staff members not following proper procedures. One Certified Nursing Assistant (CNA) did not remove personal protective equipment (PPE) correctly after exiting an isolation room, instead discarding it in the hallway. Another staff member, a Certified Occupational Therapist Assistant (COTA), did not properly disinfect a wheelchair before moving it from an isolation room to a therapy gym, acknowledging that the equipment should have been cleaned thoroughly inside the resident's room. Additionally, there were instances of staff failing to perform hand hygiene. One CNA handled a resident's food with bare hands after touching potentially contaminated items, while another CNA moved a floor mat and then assisted a resident with their meal without performing hand hygiene. These actions were observed during dining services and involved residents with various medical conditions, including COVID-19, influenza, and dementia. The deficiencies were confirmed through interviews with the Director of Nursing (DON) and the Infection Control Preventionist (ICP), who acknowledged the lapses in protocol adherence. The report highlights the need for staff to follow established procedures for PPE removal, equipment disinfection, and hand hygiene to prevent the spread of infections within the facility.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by several incidents involving staff interactions with residents during meal times. One incident involved a Certified Nursing Assistant (CNA) standing over a resident with heart disease, dementia, and depression to assist with feeding, which was acknowledged by the CNA as inappropriate. Another incident involved a CNA addressing a resident with severe cognitive impairment in an informal manner, using the term "girl," which is not in line with the facility's policy of using courtesy titles. Additionally, during a dining observation, a CNA referred to two residents as "feeders" in the hallway, which was confirmed by the Director of Nursing as inappropriate. The residents involved had varying degrees of cognitive impairment and required different levels of assistance with meals. These actions were contrary to the facility's policy on promoting and maintaining resident dignity, which emphasizes treating residents with respect and recognizing their individuality.
Failure to Maintain Sanitary Conditions in Shared Bathrooms
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment in shared bathrooms for several residents. Observations revealed that personal hygiene items such as wash basins, bedpans, toothbrush holders, and denture cups were found unlabeled and uncontained in shared bathrooms. These items were often placed on the floor, on the back of toilets, or on sinks, contrary to the facility's policy of storing them in designated areas like bedside tables or wardrobes. The residents involved had various medical conditions, including chronic diseases, cognitive impairments, and dependencies on staff for activities of daily living (ADLs) and toileting. Many of the residents were incontinent of bowel and bladder, requiring assistance with personal hygiene. The lack of proper labeling and containment of personal hygiene items posed a risk of cross-contamination and did not honor the residents' right to a safe and homelike environment. During an interview, the Director of Nursing confirmed that the facility's policy required personal hygiene items to be stored in plastic bags and placed in specific storage areas, not left in bathrooms. The failure to adhere to these guidelines was observed in multiple shared bathrooms, affecting numerous residents and indicating a systemic issue in maintaining sanitary conditions within the facility.
Failure to Revise Care Plans for Residents with Health Changes
Penalty
Summary
The facility failed to revise care plans for four residents experiencing various health issues, including pressure ulcers, COVID-19, and influenza. Resident #12, who was admitted with multiple diagnoses including dementia and peripheral vascular disease, developed unstageable pressure ulcers on both heels. Despite the presence of these pressure injuries, the care plan was not updated to address the prevention and treatment of these ulcers. The Director of Nursing confirmed that the care plan should have been revised to reflect the resident's risk and treatment for pressure ulcers. Resident #38 tested positive for COVID-19, and although the resident was placed in isolation with appropriate precautions, the care plan was not updated until seven days after the positive test result. The Director of Nursing and the Infection Control Preventionist acknowledged that the care plan should have been revised to include the infection and transmission-based precautions. Similarly, Resident #80, who was diagnosed with influenza, was moved to droplet isolation, but the care plan did not reflect this status change. The Director of Nursing confirmed the omission in the care plan documentation. Resident #92, who was also diagnosed with COVID-19, was placed in transmission-based precautions, but the care plan was not updated to reflect this. The Director of Nursing and the Infection Control Preventionist confirmed that the care plan should have been revised to include the infection and precautions. These deficiencies highlight the facility's failure to adhere to its policy of revising care plans upon a resident's status change, as evidenced by the lack of timely updates to the care plans for these residents.
Misclassification of Pressure Wounds Leads to Deficiency
Penalty
Summary
The facility failed to correctly stage pressure wounds for a resident, leading to a deficiency in pressure ulcer care. The facility's policy on Pressure Injury Prevention and Management requires clear identification of pressure injury stages and the development of a care plan with measurable goals and interventions. However, the medical record review revealed that the resident, who was admitted with multiple diagnoses including dementia and peripheral vascular disease, did not have a care plan for pressure injuries. Initial and weekly wound assessments incorrectly identified the resident's heel wounds as non-pressure vascular wounds, despite the facility's pressure ulcer list and a wound care company's evaluation indicating they were deep tissue pressure injuries. Observations and interviews further confirmed the misclassification of the wounds. During an observation, the wound nurse identified the resident's heel wounds as deep tissue injuries, not vascular. The Director of Nursing confirmed that a physician's diagnosis is required to classify a wound as vascular and that the wound nurse is expected to stage wounds correctly. This misclassification led to improper care and treatment of the resident's wounds, as the facility did not adhere to its policy for pressure injury management.
Failure to Secure Hazardous Items in Resident Rooms
Penalty
Summary
The facility failed to maintain an environment free of accident hazards, as evidenced by the presence of hazardous personal items in resident rooms. Resident #2, who was moderately cognitively impaired and required assistance with activities of daily living, had several potentially hazardous items, including an air freshener and body sprays, stored on a wooden bookshelf in their room. These items were easily accessible and not stored in a manner that would prevent resident access, contrary to the facility's policy. Both a Licensed Practical Nurse and the Director of Nursing confirmed that these items should have been stored in plastic bags and kept out of reach in the resident's drawer. Similarly, Resident #71, who was also moderately cognitively impaired and required supervision for activities of daily living, had an unsecured disposable razor left unattended on the bathroom vanity. The resident was mobile via wheelchair, which could have facilitated access to the razor. The Director of Nursing confirmed that the razor should not have been left unsecured and should have been placed in a sharps container. These oversights indicate a failure to adhere to safety protocols designed to protect residents from potential hazards.
Incomplete Daily Staffing Postings
Penalty
Summary
The facility failed to post the scheduled total number of full-time employees (FTEs) and their total FTE hours for each shift, as well as the total actual hours worked by licensed and unlicensed staff responsible for resident care, for all 31 sampled days. A review of the facility's Today's Staffing documents from December 9, 2024, to January 10, 2025, revealed these omissions. During an interview, the Scheduler confirmed that the daily staff postings were incomplete and should have included the number of FTEs scheduled, the total hours worked every shift for both licensed and non-licensed staff, and any changes due to call-ins. The Director of Nursing also confirmed the incompleteness of the daily staff postings, emphasizing the need for them to reflect the total FTEs and hours worked by both licensed and non-licensed staff, including any changes due to call-ins.
Improper Documentation and Management of Narcotic Medications
Penalty
Summary
The facility failed to properly document and manage narcotic medications, leading to discrepancies in narcotic counts and improper documentation of medication administration and destruction. The facility's policy on controlled medications requires clear documentation and accountability for all doses, including those administered, wasted, or destroyed. However, the facility did not adhere to these guidelines, resulting in multiple instances of improper documentation and unresolved discrepancies. For Resident #57, the facility failed to document the administration of Hydrocodone/APAP on the Medication Administration Record (MAR) and did not properly account for doses that were signed out in error or wasted. The Controlled Drug Receipt/Record/Disposition Form showed inconsistencies in the number of tablets left after administration, and the medication was not documented as given or wasted on certain dates. Similarly, for Resident #258, there was a discrepancy between the quantity of Gabapentin left after the last documented administration and the quantity destroyed, which was not identified by the staff or during the drug destruction process. Resident #353's Lorazepam administration was also improperly documented, with entries being crossed out incorrectly and no documentation of medication being wasted. The discrepancies in the narcotic counts and documentation were not identified by the staff responsible for placing medications in the drop box or during the drug destruction process. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, confirmed these documentation errors and discrepancies, which were not investigated or resolved in a timely manner.
Improper Storage and Security of Medications
Penalty
Summary
The facility failed to ensure the proper storage and security of medications when a staff member, identified as the Wound Nurse, left a treatment cart unlocked, unattended, and out of sight. This incident was observed on the 300 hall, where the Director of Nursing (DON) confirmed that medications were present on the cart and acknowledged that it should not have been left unlocked and unattended. Further observation on the 300/400 hall revealed various medications used for treating wounds and skin issues, including Medihoney, B & C wound dressing, hydrogel, Mipircron ointment, and Nyamyc topical powder, were left unsecured on the treatment cart. The Wound Nurse confirmed these medications were used for wounds and skin issues, indicating a breach of the facility's policy on medication storage, which mandates that all drugs and biologicals be stored in locked compartments accessible only to authorized personnel.
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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