Rocky Top Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rocky Top, Tennessee.
- Location
- 204 Industrial Park Rd, Rocky Top, Tennessee 37769
- CMS Provider Number
- 445259
- Inspections on file
- 19
- Latest survey
- August 22, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rocky Top Care Center during CMS and state inspections, most recent first.
The facility failed to handle residents' laundry safely, exposing them to pathogens, and allowed COVID-19 positive staff to work with non-COVID-19 residents, increasing infection risk. Additionally, inadequate staffing led to missed outpatient appointments and showers for residents.
The facility's QAPI program failed to identify and address deficiencies in infection control practices, leading to improper handling of residents' laundry and premature return of COVID-19 positive staff. This oversight resulted in a COVID-19 outbreak affecting 22 residents and 13 employees, with seven staff returning to work before completing isolation. The facility also had repeated abuse-related deficiencies, which were not effectively addressed by the QAPI committee.
The facility failed to maintain sanitary conditions for residents' personal laundry, which was improperly handled and stored, leading to insufficient cleaning. Additionally, the facility did not adhere to CDC guidelines for excluding COVID-19 positive employees from work during an outbreak, increasing the risk of virus spread. The facility also failed to post Enhanced Barrier Precautions signage on three resident rooms, placing residents at risk of serious harm.
The facility's Governing Body failed to address unsafe handling of residents' laundry and allowed COVID-19 positive staff to work with non-COVID-19 residents, exposing all residents to infection. The QAPI program did not identify or address these deficiencies, leading to a COVID-19 outbreak affecting 22 residents and 13 employees.
The facility failed to maintain adequate staffing, resulting in two residents missing outside physician appointments and five residents not receiving scheduled showers. Interviews and documentation revealed that low staffing levels often prevented CNAs and LPNs from completing scheduled care tasks. The facility's staffing goals were not met, leading to unmet care needs.
A dietary aid in the facility's kitchen was observed without a protective beard covering, violating the facility's sanitary practices policy. The policy requires all hair, including facial hair, to be covered to ensure sanitary conditions. The Dietary Manager confirmed the oversight, which had the potential to affect all 90 residents.
The facility failed to provide scheduled showers for five residents due to staffing issues, despite residents not refusing care. Staff interviews revealed that CNAs and LPNs were unable to complete scheduled showers due to high resident-to-staff ratios. The Director of Nursing Services and the Administrator acknowledged the staffing concerns, confirming that some residents did not receive their scheduled showers.
The facility did not serve meals simultaneously to residents seated at the same table during a lunch meal, violating their right to a dignified existence. Several residents experienced delays in receiving their meals, with one resident waiting 13 minutes after expressing hunger and another receiving their meal 17 minutes after others at the same table. An error was also noted where a meal was left in a resident's room, causing further delay.
A deficiency was identified in a facility's ADL documentation for several residents, revealing incomplete and inaccurate records of scheduled showers. Interviews with CNAs indicated that low staffing levels often prevented them from providing scheduled showers or completing documentation. The DNS confirmed the discrepancies, acknowledging that the incomplete records resulted in an inaccurate medical record.
A facility failed to maintain a clean and homelike environment for a resident with severe cognitive impairment. The resident's bathtub was repeatedly observed with dead insects and dirt-like substances, which was confirmed by the Administrator as unsanitary and not in line with the facility's policy for a safe and comfortable environment.
Two incidents of resident-to-resident abuse occurred in the facility, involving residents with severe cognitive impairments. In one case, a resident punched another in the face, and in the second case, a resident struck another twice. Both incidents were witnessed by staff, who intervened, but the facility failed to prevent the abuse despite existing care plans for aggressive behavior.
The facility failed to provide transportation for two residents to their scheduled medical appointments due to insufficient staff. One resident missed multiple urology appointments, while another missed a gastroenterology appointment. Despite the missed appointments, facility staff indicated that no harm resulted to the residents.
Expired medications and supplies were found in a medication room, including syringes, suppositories, and Heparin Lock Flush Solutions. An LPN confirmed these items were expired and available for resident use, contrary to the facility's policy requiring their removal and disposal. The DNS acknowledged the oversight.
The facility failed to properly contain garbage and refuse in three dumpsters, as required by their 'Waste Control' policy. During an observation, it was found that dumpsters A, B, and C were missing drain plugs, leaving openings that exposed the contents to the air and potential pests. The Dietary Manager confirmed the absence of drain plugs, leading to improper containment.
The facility's assessment failed to include staffing parameters for the secure unit, contingency staffing protocols, and changes in laundry services. It also lacked input from direct-care staff, residents, or families.
The facility failed to report abuse allegations to the state agency within the required 2-hour timeframe for six residents, resulting in significant delays. Residents with cognitive impairments experienced delays in reporting incidents of verbal and physical abuse, with some reports delayed by over 20 hours. Interviews confirmed the facility's failure to adhere to mandatory reporting requirements.
The facility failed to conduct thorough investigations for injuries of unknown origin and abuse allegations involving several residents with cognitive impairments. A resident sustained a rib fracture without a complete investigation, and another incident involved resident-to-resident altercations without proper documentation or interviews. Additionally, the facility did not notify physicians or family representatives after abuse allegations, and the Administrator acknowledged issues with incomplete investigations.
The facility failed to protect residents from verbal and physical abuse. A resident with moderate cognitive impairment reported verbal abuse by a CNA, which was substantiated. Additionally, two residents with severe cognitive impairment were involved in a physical altercation, resulting in injury. Another resident attempted to assault a fellow resident but was stopped by staff. The facility's administrator confirmed these failures.
The facility did not update care plans for four residents after incidents of abuse and allegations of abuse, despite policy requirements. A resident with moderate cognitive impairment reported verbal abuse by a CNA, and another resident reported a CNA being rude and threatening, but their care plans were not revised. Additionally, two residents involved in a resident-to-resident altercation did not have their care plans updated. The DON confirmed the care plans were not revised following these incidents.
The facility did not submit required PBJ data to CMS for four consecutive quarters, covering the 3rd and 4th Quarters of 2022 and the 1st and 2nd Quarters of 2023. The Administrator admitted responsibility for the oversight during an interview.
Inadequate Infection Control and Staffing in LTC Facility
Penalty
Summary
The facility's administration failed to ensure the safe and sanitary handling, storage, processing, and transportation of residents' personal laundry, potentially exposing 85 of 90 residents to infectious pathogens. The facility had ceased using a commercial laundry service and instead transported soiled laundry to a local laundromat, where it was washed without proper sanitizing agents and at insufficient water temperatures. Observations revealed that residents' laundry was stored in unsanitary conditions, with dried feces and urine, and not separated, leading to potential microbial contamination. Additionally, the administration failed to exclude COVID-19 positive employees from work for the required isolation period as recommended by the CDC. During a COVID-19 outbreak, the facility allowed symptomatic and COVID-19 positive staff to work with non-COVID-19 residents, increasing the risk of spreading the infection. Interviews confirmed that several employees returned to work before completing the recommended quarantine period, contrary to CDC guidelines. The facility also failed to maintain adequate staffing levels, resulting in two residents missing scheduled outpatient appointments due to insufficient staff for transportation. Furthermore, five residents did not receive their scheduled showers due to staffing shortages. Interviews with staff and administration confirmed awareness of these staffing issues, which impacted the facility's ability to meet residents' care needs, including transportation and personal hygiene.
Inadequate Infection Control and QAPI Oversight
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to effectively identify and address quality deficiencies, particularly in infection control practices. The QAPI committee did not recognize the poor infection control measures in place, which included improper handling, storage, processing, and transportation of residents' personal laundry. This oversight had the potential to expose residents to infectious pathogens. Additionally, the facility did not update staff with the latest Centers for Disease Control (CDC) guidelines for isolation and quarantine times for COVID-19 positive employees, resulting in COVID-19 positive staff returning to work prematurely and potentially exposing residents to the virus. The facility experienced a COVID-19 outbreak, during which 22 residents and 13 employees tested positive. Despite this, seven COVID-19 positive employees were allowed to return to work before completing the recommended isolation period. The QAPI meeting minutes from June and July 2024 did not document any identification or reporting of these quality deficiencies, nor did they show any root cause analysis or corrective action plans related to the infection control program and practices. The facility also had repeated deficiencies related to abuse, which were not addressed by the QAPI committee. The facility's administration failed to address the widespread problem of unsafe and unsanitary handling of residents' personal laundry and the premature return of COVID-19 positive employees to work. This failure resulted in an Immediate Jeopardy situation, as the noncompliance with infection control practices had the potential to cause serious harm to all 90 residents. The facility had been previously cited for abuse-related deficiencies, indicating a pattern of noncompliance that the QAPI committee did not effectively address.
Infection Control and COVID-19 Protocol Failures
Penalty
Summary
The facility failed to maintain sanitary conditions for residents' personal laundry, which was stored in a large green bin filled with uncontained soiled clothing items. Observations revealed that the clothing had dried brown substances, smelled of urine, and was difficult to unfold, indicating a lack of proper handling and storage. The facility's process involved placing soiled clothes in a community rolling hamper, bagging them, and storing them in a building behind the facility. The laundry was then taken to a local laundromat, where it was washed without proper separation or the use of necessary chemicals and hot water, leading to insufficient cleaning. Additionally, the facility did not adhere to CDC guidelines for excluding COVID-19 positive employees from work during a COVID-19 outbreak. Employees were not restricted from work for the required isolation period, increasing the risk of exposure and spread of the virus among residents. The facility's outdated COVID-19 policy did not align with the CDC's updated guidance, which required specific criteria for healthcare personnel to return to work after testing positive for COVID-19. The facility also failed to post Enhanced Barrier Precautions signage on the doors of three resident rooms, which is crucial for infection control. This oversight, combined with the improper handling of personal laundry and non-compliance with COVID-19 protocols, placed residents at risk of serious harm. The facility's actions and inactions during the COVID-19 outbreak and in managing personal laundry contributed to the deficiencies identified by the surveyors.
Inadequate Infection Control and Laundry Handling
Penalty
Summary
The facility's Governing Body failed to address significant issues related to the unsafe and unsanitary handling, storing, and processing of residents' contaminated and potentially hazardous personal laundry. This failure had the potential to expose infectious pathogens to 85 of the 90 residents who utilized the facility's laundry service. Additionally, the Governing Body did not provide effective leadership and oversight to ensure that COVID-19 positive employees were excluded from work for the required isolation period as recommended by the Centers for Disease Control (CDC). This oversight allowed COVID-19 positive staff to work with non-COVID-19 residents, thereby exposing all 90 residents to the risk of infection. The facility experienced a COVID-19 outbreak from June to August 2024, during which 22 residents and 13 employees tested positive for the virus. Interviews revealed that seven employees returned to work before completing the CDC-recommended quarantine period. The facility's Quality Assurance and Performance Improvement (QAPI) program failed to identify and address quality deficiencies, perform root cause analyses, or develop corrective action plans related to the infection control program and laundry services. The QAPI meeting minutes from June and July 2024 showed no documentation of efforts to address these issues. The facility's administration and Governing Body did not adequately address the widespread problems of infection control and laundry handling in their QAPI meetings. The Administrator acknowledged areas needing improvement in infection prevention and control practices. The facility's policies and procedures, including those related to the Governing Body's responsibilities, were not effectively implemented to ensure compliance with state and federal regulations, thereby placing residents in Immediate Jeopardy.
Staffing Shortages Lead to Missed Appointments and Unmet ADL Needs
Penalty
Summary
The facility failed to maintain adequate staffing levels, resulting in two residents missing scheduled transportation to outside physician appointments. One resident, who was cognitively intact, missed multiple urology appointments due to transportation issues caused by insufficient staff. Another resident, with moderate cognitive impairment, missed an appointment with a stomach doctor because there was not enough staff available to transport or assist him to the appointment. The Director of Nursing Services and the Administrator confirmed these incidents were due to staffing shortages. Additionally, the facility did not meet the ADL needs of five residents, specifically in providing scheduled showers. Residents who required assistance or supervision for showers did not receive them as scheduled, with some receiving no showers for entire months. Interviews with CNAs and LPNs revealed that low staffing levels often prevented them from completing scheduled showers, despite residents not refusing them. The facility's staffing schedule and actual punch times showed discrepancies, with shifts often operating with fewer staff than planned. The facility's staffing goals were not met, as confirmed by the Director of Nursing Services and the Administrator. The secure unit, east hallway, and west hallway frequently operated with fewer CNAs and nurses than required, leading to unmet care needs. The Administrator acknowledged awareness of staffing concerns and confirmed that some residents did not receive scheduled showers due to these issues. The facility's assessment indicated a need for more staff than were actually scheduled, contributing to the deficiencies in resident care.
Non-compliance with Sanitary Practices in Kitchen
Penalty
Summary
The facility failed to ensure compliance with its sanitary practices policy, specifically regarding the requirement for kitchen staff to wear protective coverings for facial hair. During an observation in the food preparation area, a dietary aid was found without a protective beard covering, which is a violation of the facility's policy dated 1/1/2017. This policy mandates that all hair, including facial hair, must be completely covered to maintain sanitary conditions. The Dietary Manager confirmed the deficiency during an interview, acknowledging that the dietary aid's beard was not fully covered while working in the kitchen, potentially affecting all 90 residents of the facility.
Failure to Provide Scheduled Showers Due to Staffing Issues
Penalty
Summary
The facility failed to provide scheduled showers for five residents, leading to a deficiency in the care and assistance with activities of daily living (ADLs). The facility's policy states that all residents have the right to a dignified existence and self-determination, which includes receiving scheduled showers. However, documentation and interviews revealed that residents did not receive their scheduled showers consistently over several months. For instance, one resident was scheduled for showers twice a week but received only a few showers over a three-month period, despite not refusing them. Interviews with staff, including CNAs and LPNs, indicated that staffing issues contributed to the failure to provide scheduled showers. Staff members reported being unable to complete the scheduled showers due to the high number of residents they were responsible for during their shifts. The Director of Nursing Services and the Administrator acknowledged the staffing concerns and confirmed that some residents had not received their scheduled showers. Observations of the residents involved showed that they were not unkempt and no odors were noted, suggesting that some level of personal care was maintained. However, the lack of documentation and completion of scheduled showers indicates a systemic issue in meeting the residents' ADL needs. The facility's failure to adhere to its own policies and ensure adequate staffing levels resulted in the deficiency noted by the surveyors.
Failure to Serve Meals Simultaneously in Dining Room
Penalty
Summary
The facility failed to honor the residents' right to a dignified existence and self-determination by not serving meals simultaneously to residents seated at the same table during a lunch meal observation. The facility's policy on Dining and Meal Service, which mandates that individuals at the same table be served and assisted at the same time, was not adhered to. This resulted in four residents experiencing delays in receiving their meals compared to others at their tables. For instance, one resident expressed hunger and had to wait 13 minutes after requesting his meal, while another resident received their meal 17 minutes after others at the same table had been served. The deficiency was further highlighted by an incident where a resident's meal was mistakenly left in their room, causing additional delay in service. The Activity Director confirmed this error during an interview. The Regional President acknowledged that residents were supposed to be served one table at a time and confirmed the untimely service during the lunch meal. The residents involved had various medical conditions, including dementia, depression, and diabetes, with some requiring assistance with eating, which underscores the importance of timely meal service.
Deficiency in ADL Documentation Due to Staffing Issues
Penalty
Summary
The facility failed to ensure the medical records were accurate and complete for four residents, leading to a deficiency in the documentation of Activities of Daily Living (ADL) care. The facility's policy requires maintaining complete and accurate records, but reviews revealed significant gaps in the documentation of scheduled showers for the residents. For instance, Resident #33, who was cognitively intact and required supervision with bathing, received significantly fewer showers than scheduled over several months, with many days left undocumented or marked as Resident Not Available (RNA) or Not Applicable (N/A). Interviews with Certified Nursing Assistants (CNAs) highlighted issues contributing to the deficiency. CNA B, who regularly worked on the resident's hall, reported that low staffing levels often prevented her from providing scheduled showers or completing documentation. Similarly, CNA C and CNA O noted that they were unable to complete scheduled showers or document them due to time constraints, despite Resident #33 not typically refusing showers. These staffing challenges and documentation lapses were consistent across the other residents reviewed, including Resident #39, who was severely cognitively impaired and dependent on staff for all ADLs, and Resident #49, who was cognitively intact but required assistance. The Director of Nursing Services (DNS) confirmed the discrepancies in the ADL bathing records during an interview, acknowledging that the residents had not received the scheduled showers and that some baths were not documented. The DNS expressed that the incomplete records resulted in an inaccurate medical record, indicating a failure to chart properly. This deficiency in maintaining accurate and complete medical records for residents' ADL care reflects a significant lapse in the facility's adherence to its own policies and professional standards.
Failure to Maintain a Clean Environment for a Resident
Penalty
Summary
The facility failed to provide a clean and homelike environment for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including difficulty walking, weakness, and lack of coordination, was observed in their room on multiple occasions with a bathtub containing dead insects and a brownish, black dirt-like substance around the drain. These observations were made over several days and confirmed by the facility's Administrator, who acknowledged that the bathtub had not been maintained in a sanitary manner, thus failing to meet the facility's policy on providing a safe, clean, and comfortable environment for residents.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two separate incidents involving resident-to-resident altercations. In the first incident, Resident #45, who has severe cognitive impairment and a history of impulsiveness, punched Resident #22, who also has severe cognitive impairment, in the face. This incident occurred in the dining room and was witnessed by a CNA, who immediately intervened. Despite the intervention, the altercation resulted in physical abuse, although no injuries were observed on Resident #22. In the second incident, Resident #13, who has severe cognitive impairment and a history of psychotic disturbances, struck Resident #54 twice in the face. This altercation was reported by another resident and witnessed by staff, who separated the residents. Resident #54, who has moderate cognitive impairment, did not sustain any visible injuries, but the incident was confirmed as physical abuse. The altercation was reportedly triggered by Resident #13's delusion involving a staff member. Both incidents highlight the facility's failure to prevent resident-to-resident abuse, despite having care plans in place for residents with aggressive tendencies. The facility's policies define such altercations as abuse, yet the incidents occurred, indicating a lapse in monitoring and intervention strategies to protect residents from harm.
Failure to Provide Transportation for Medical Appointments
Penalty
Summary
The facility failed to ensure professional standards of practice were followed when transportation was not provided to outpatient scheduled appointments for two residents. Resident #9, who was cognitively intact and had a history of chronic urinary retention and recurrent urinary tract infections, missed multiple urology appointments due to transportation issues. Despite being ready and waiting for transportation, the resident missed appointments on several occasions, including 6/11/2024, 7/22/2024, and 8/13/2024, and was late for an appointment on 6/25/2024, which had to be rescheduled. The Director of Nursing Services confirmed that the missed appointments were due to insufficient staff to provide transportation. Resident #83, who had moderate cognitive impairment and a history of chronic pain and liver disease, also missed a scheduled appointment with a gastroenterologist. The appointment was intended to establish care with a new specialist due to the resident's history of ascites from cirrhosis of the liver. The appointment was scheduled for 8/13/2024 but was rescheduled due to a lack of available staff to transport or assist the resident. The facility's Resident Appointment Scheduler and Administrator confirmed the rescheduling was due to staffing issues. Interviews with facility staff, including the Medical Director and Nurse Practitioner, indicated that the missed appointments did not result in harm to the residents. However, the failure to provide transportation as needed for scheduled medical appointments represents a deficiency in meeting professional standards of care and ensuring residents' rights to access necessary medical services outside the facility.
Expired Medications and Supplies Found in Medication Room
Penalty
Summary
The facility failed to ensure that expired medications and medical supplies were not available for resident use in one of the two medication rooms observed. During an observation and interview in the East medication room, an LPN identified several expired items, including 18 syringes of various sizes, 86 suppositories, and 2 Heparin Lock Flush Solutions. These items were confirmed to be expired and were still stored in the medication room, making them available for resident use. The facility's policy on medication storage, revised in April 2022, mandates the immediate removal and disposal of expired medications. However, during an interview, the Director of Nursing Services confirmed that the expired items should have been removed and placed into the pharmacy return bin for disposal. The failure to adhere to the facility's policy resulted in the availability of expired medications and supplies in the East medication room.
Improper Containment of Garbage in Dumpsters
Penalty
Summary
The facility failed to ensure that garbage and refuse were properly contained in three dumpsters, labeled A, B, and C. According to the facility's policy titled 'Waste Control,' dated January 1, 2012, dumpsters must be kept closed at all times to maintain sanitary conditions. However, during an observation of the outside dumpster area, it was found that all three dumpsters were missing drain plugs, leaving a golf-ball sized opening at the bottom corner of each dumpster. This deficiency left the contents of dumpsters A, B, and C exposed to the air, elements, and potential pests. The Dietary Manager confirmed during an interview that the drain plugs were not intact, resulting in improper containment of the dumpster contents.
Incomplete Facility Assessment
Penalty
Summary
The facility failed to complete a comprehensive facility-wide assessment that accurately reflected the needs and services provided. The assessment, dated 7/28/2024, did not include staffing parameters for the secure unit or contingency staffing protocols for emergency and crisis situations. Additionally, the assessment did not reflect changes in the facility's laundry service or the building modification plans to add an in-house laundry room. Furthermore, there was no documentation indicating that input from direct-care staff, residents, or resident families was considered in the assessment process. During an interview, the Administrator confirmed these omissions in the facility assessment.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the state agency within the required 2-hour timeframe for six residents. The facility's policy mandates that any alleged violations involving abuse or resulting in serious bodily injury must be reported immediately, but no later than 2 hours after the allegation is made. However, the facility did not adhere to this policy, resulting in significant delays in reporting incidents of abuse. Resident #1, who had moderate cognitive impairment, reported feeling afraid of a Certified Nurse Assistant (CNA) and did not want care from them. The incident was reported to the state agency 8 hours and 25 minutes after it was identified. Similarly, Resident #3, also with moderate cognitive impairment, experienced a delay of 9 hours in reporting an allegation of verbal abuse. Resident #4 and Resident #22 were involved in a physical altercation, which was reported 20 hours and 32 minutes after the incident occurred. Additionally, an altercation between Resident #11 and Resident #12, both with cognitive impairments, was reported 9 hours and 45 minutes after it was identified. Interviews with the Director of Nursing Services (DNS) and the Administrator confirmed the facility's failure to report these incidents within the mandatory timeframe. The facility's inability to report these allegations promptly constitutes a deficiency in adhering to regulatory requirements for reporting abuse.
Incomplete Investigations of Injuries and Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations for injuries of unknown origin and allegations of abuse involving several residents. For Resident #13, who had moderate cognitive impairment and was diagnosed with dementia, depression, and seizures, the facility did not complete a comprehensive investigation after the resident sustained a rib fracture. There was no documentation of staff or resident interviews following the identification of the injury, and the Director of Nursing Services (DNS) confirmed that the investigation was incomplete. In another incident, the facility did not perform adequate investigations for resident-to-resident altercations involving Residents #11 and #12, who had moderate to severe cognitive impairments. A Certified Nursing Assistant (CNA) heard yelling in their room and observed red marks on Resident #11, but the facility failed to document skin assessments or conduct interviews with the involved residents and staff. The DNS acknowledged that the investigation was not thorough. Additionally, the facility did not notify the physician or family representatives after allegations of abuse involving Residents #1 and #3, both of whom had moderate cognitive impairments. Resident #1 expressed fear of a CNA, and Resident #3 reported being treated rudely by the same CNA. The facility also failed to conduct complete investigations for an altercation between Residents #4 and #22, neglecting to perform skin assessments and interviews. The Administrator admitted to issues with incomplete investigations.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from verbal abuse and prevent resident-to-resident abuse among four residents. Resident #1, who had moderate cognitive impairment, reported verbal abuse by CNA D, which was substantiated by the facility's investigation. Similarly, Resident #3, also with moderate cognitive impairment, reported that CNA D was rude and talked down to him, which was confirmed by the facility's administrator. In another incident, Resident #27, with severe cognitive impairment, was involved in a physical altercation with Resident #28, who also had severe cognitive impairment. The altercation occurred in the dining room, where Resident #27 hit Resident #28 in the face, resulting in a scratch on Resident #28's face. The facility's investigation confirmed the occurrence of resident-to-resident physical abuse. Additionally, Resident #22, with severe cognitive impairment, attempted to physically assault Resident #4, who had moderate cognitive impairment. Resident #22 was found holding Resident #4's forearms and rearing back with a clenched fist, but intervention by staff prevented further harm. Despite these interventions, the facility failed to protect these residents from physical abuse, as confirmed by the administrator.
Failure to Revise Care Plans After Abuse Allegations
Penalty
Summary
The facility failed to revise comprehensive care plans for four residents following incidents of abuse and allegations of abuse. The facility's policy requires care plans to be revised as residents' conditions change, including after resident-to-resident altercations. However, the care plans for Residents #3, #1, #4, and #22 were not updated after incidents involving verbal abuse and resident-to-resident altercations. Resident #3, who has moderate cognitive impairment, reported verbal abuse by a CNA, but their care plan was not revised. Similarly, Resident #1, who also had moderate cognitive impairment, reported a CNA being rude and threatening, yet their care plan remained unchanged. Additionally, Resident #4, with moderate cognitive impairment, and Resident #22, with severe cognitive impairment, were involved in a resident-to-resident altercation. The facility's investigation documented that Resident #4 held Resident #22's forearms, but neither resident's care plan was updated to reflect this incident. The Director of Nursing Services confirmed that the care plans for these residents were not revised following the allegations of abuse, indicating a failure to adhere to the facility's policy on care plan revisions.
Failure to Submit PBJ Data for Four Quarters
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for four consecutive quarters, specifically the 3rd and 4th Quarters of 2022 and the 1st and 2nd Quarters of 2023. This deficiency was identified through a review of the Quarterly Payroll Based Journal (PBJ) reports, which revealed the absence of submitted data for these periods. During an interview, the Administrator acknowledged that it was his responsibility to submit the PBJ data and confirmed that he did not fulfill this obligation for the specified quarters.
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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