Signature Health Of Portland Rehab & Wellness Cent
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Tennessee.
- Location
- 215 Highland Circle Drive, Portland, Tennessee 37148
- CMS Provider Number
- 445306
- Inspections on file
- 17
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Signature Health Of Portland Rehab & Wellness Cent during CMS and state inspections, most recent first.
A resident with multiple medical conditions and moderate cognitive impairment experienced a severe weight loss of over 7% in one week. Despite facility policies requiring monitoring and intervention for significant weight changes, there was no evidence that the RD or staff implemented or documented any interventions or follow-up after the weight loss was identified. Staff interviews confirmed that the expected process for addressing nutritional risk was not followed, resulting in actual harm.
A resident with paraplegia and a neurogenic bladder suffered third-degree burns after urine from self-catheterization contacted a power strip placed in the bed by the administrator. Despite staff awareness of the resident's incontinence, use of multiple electronics in bed, and safety concerns, there was no documented assessment, care plan intervention, or consistent monitoring to address the risks. The lack of appropriate actions and oversight led to the resident sustaining severe electrical burns.
A resident with a history of respiratory failure and COPD, who had clearly documented full code status and a preference for resuscitation, was found unresponsive by nursing staff. Despite being aware of the resident's wishes and physician orders, staff did not initiate CPR, citing the resident's physical appearance. This failure to provide BLS/CPR as required led to a citation for substandard quality of care.
The facility failed to provide adequate supervision and maintain a safe environment, resulting in serious incidents including a resident being electrocuted by a power strip in bed and another resident suffering a fatal fall after being left unattended. Multiple residents were found with electrical devices and cords in their beds, and staff reported unclear procedures and insufficient training regarding electrical safety. The facility lacked proper documentation and protocols for testing and maintaining patient care-related electrical equipment, contributing to ongoing accident hazards.
A resident suffered third-degree electrical burns after urine contacted an energized power strip in bed, requiring emergency evaluation. The QAPI committee did not maintain documentation or monitor the effectiveness of interventions following the incident, and ongoing noncompliance with electrical safety practices was observed, including residents with charging cords in bed and a lack of care plan interventions.
A resident with paraplegia and a neurogenic bladder, who self-catheterized and had a history of incontinence, sustained third-degree electrical burns after urine leaked into a power strip placed in bed. The facility did not assess the resident's ability to use the power strip safely, failed to include necessary interventions in the care plan, and did not report the incident of neglect with physical harm to the State Survey Agency as required.
A resident with complex medical and behavioral needs was not permitted to return to the facility after hospitalization for acute confusion and infection. Despite stabilization and no evidence of ongoing aggression, the administrator informed hospital staff and the resident's family that the resident would not be allowed back, contrary to facility policy and regulatory requirements. Staff interviews indicated the resident's behaviors were related to his medical condition, and the resident was not given the option to return.
A resident with paraplegia suffered second-degree burns in a shower room due to a malfunctioning hot water heater that had been leaking steam and hot water. Despite multiple reports from staff about the issue, the shower room remained in use, and the Administrator's instructions to manage the problem were inadequate. The resident, unable to feel below the waist, was unaware of the danger until injured, highlighting a significant neglect in ensuring resident safety.
A resident with paraplegia sustained second-degree burns on the left foot due to a malfunctioning hot water heater in the shower room, which reached temperatures of 169°F. Despite prior reports of steam and hot water leaks, the facility failed to address the issue, leading to Immediate Jeopardy. Staff were instructed to manage the situation by turning on faucets in adjacent rooms, rather than shutting down the malfunctioning shower room.
A facility's administration failed to address a malfunctioning hot water heater, resulting in a resident suffering a major burn injury. Despite multiple reports from staff about the hazard, the Administrator did not take appropriate action to ensure safety, leading to Immediate Jeopardy citations for substandard care.
Failure to Address Severe Weight Loss and Nutritional Risk
Penalty
Summary
The facility failed to assess and address the nutritional status of a resident who experienced a severe weight loss of 7.07% within a one-week period. The resident, who had multiple diagnoses including metabolic encephalopathy, neurogenic bladder, BPH, diabetes, and a urinary tract infection, was moderately cognitively impaired and required assistance with eating. Despite a significant weight loss being documented, there was no evidence that the registered dietitian (RD) or facility staff implemented or documented any interventions to address the weight loss or prevent further decline. Facility policies required regular monitoring of weights, prompt notification of significant changes, and individualized nutritional interventions. The resident's weight dropped from 230.5 lbs to 214.2 lbs in one week, and subsequent laboratory results showed low total protein and albumin levels, indicating poor nutritional status. There was no documentation of RD follow-up or progress notes after the initial evaluation, and no evidence of reweighing or new interventions following the significant weight loss. Interviews with staff confirmed that the expected process for addressing significant weight changes was not followed, and the RD was not notified or did not document any follow-up actions. Staff interviews revealed that while CNAs reported poor intake to nurses and offered snacks, and nurses were aware of the need to monitor and report weight changes, the required escalation to the RD and implementation of further interventions did not occur. The DON and other staff confirmed that there was no RD documentation after the weight loss was identified, and the process for monitoring and addressing nutritional risk was not followed as outlined in facility policy. This failure resulted in actual harm to the resident.
Neglect Resulting in Severe Electrical Burns Due to Unsafe Use of Power Strip
Penalty
Summary
A deficiency occurred when a resident with paraplegia, bilateral leg amputations, and a neurogenic bladder sustained third-degree burns to 4% of his body after urine from a self-catheterization or incontinence episode contacted an energized power strip that was positioned in his bed. The resident, who was functionally dependent for many activities and had a history of incontinence, was provided a power strip by the facility administrator after his extension cord was removed. There was no documented assessment of the resident's ability to safely use the power strip, nor was there any care plan addressing the risks associated with electrical devices in the bed, despite the resident's known incontinence and use of multiple electronic devices in bed. Staff interviews and medical record reviews revealed that the resident frequently kept electronics, charging cords, and other items in his bed, and staff were aware of his incontinence and the risk of spillage during self-catheterization. Multiple staff members, including CNAs and nurses, observed the power strip in the bed and reported safety concerns to administration, but there was no evidence of consistent monitoring, intervention, or documentation of the resident's refusals or noncompliance. The care plan did not include interventions related to the safe use of electrical devices, noncompliance behaviors, or monitoring of self-catheterization competency, even though the resident was receiving medications that could cause drowsiness and further increase risk. On the day of the incident, the resident self-catheterized and subsequently experienced an electric shock, resulting in severe burns. The power strip was found melted and deformed, and the resident required emergency medical attention. Staff confirmed that no education or monitoring regarding the safe use of electrical devices in bed had been provided prior to the incident. The facility's failure to assess, monitor, and implement appropriate interventions to prevent physical harm constituted neglect and resulted in actual harm to the resident.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to initiate and provide Basic Life Support (BLS), including Cardiopulmonary Resuscitation (CPR), to a resident who was designated as full code status. According to the facility's policies and the resident's documented preferences, staff were required to perform CPR unless there was a written physician order to the contrary. On the date of the incident, nursing staff found the resident unresponsive, without respirations or a palpable pulse, but did not attempt to perform BLS/CPR as required by both the resident's wishes and physician orders. The resident involved had a medical history that included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD) with acute exacerbation, and pneumonia. The resident was admitted and readmitted to the facility, with documentation confirming full code status and a clear preference for resuscitation efforts in the event of cardiac or respiratory arrest. The medical record, care conference notes, and the Tennessee Physician Orders for Scope of Treatment (POST) form all indicated the resident's desire for full code status, which was discussed and confirmed with both the resident and their representative. On the morning of the incident, the registered nurse assigned to the resident found them unresponsive during routine medication administration. Despite being aware of the resident's full code status, the nurse did not initiate CPR, citing the resident's physical appearance, such as blue fingers and discoloration of the lower extremities, as the reason. Another staff member was told by the nurse that the resident was a Do Not Resuscitate (DNR), which was not accurate. Interviews with other staff and the resident's family confirmed that the expectation was for life-saving measures to be performed in accordance with the resident's wishes. The facility's failure to provide BLS/CPR as required resulted in a citation for substandard quality of care.
Failure to Prevent Accidents and Maintain a Safe Environment
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free from accident hazards, resulting in avoidable accidents involving five residents. One resident, a bilateral amputee with paraplegia and neurogenic bladder, was electrocuted while lying in bed after urine contacted an energized power strip that had been provided by the Administrator and placed in the resident's bed. This incident resulted in third-degree burns to 4% of the resident's body. Staff and other residents reported that the resident frequently kept electronic devices and cords in bed, and concerns about safety had been voiced to administration, but no effective interventions were implemented to prevent the accident. Staff interviews revealed a lack of clear procedures for approving and monitoring electrical devices, and maintenance did not keep logs or have a set schedule for checking cords and devices. Another resident, who was cognitively impaired, legally blind, and at high risk for falls, was left unattended in the bathroom after being assisted there by staff. The resident stood up and fell, sustaining a left pubic root fracture that resulted in a fatal hemorrhage. The cause of death was documented as blunt force injury of the pelvis. The resident's care plan identified a high risk for falls and required staff assistance with transfers, but staff failed to provide the necessary supervision at the time of the incident. The resident had a history of falls and required substantial assistance with mobility and activities of daily living. Additional residents were observed with electrical devices and charging cords in their beds or attached to bed rails, despite care plans noting noncompliance with electrical device safety. Staff and residents reported that concerns about electrical hazards were not addressed until after state surveyors were present. Facility documentation revealed a lack of policies and procedures for testing patient care-related electrical equipment according to NFPA standards, and numerous devices with deficiencies were identified without records of repair. Staff education on electrical safety was inconsistent or lacking, and there was no evidence of systematic monitoring or enforcement of safety protocols related to accident hazards.
Failure to Implement and Monitor QAPI Interventions for Resident Safety
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee implemented and monitored effective interventions to maintain a safe environment for residents. Despite having a policy in place requiring systematic monitoring and evaluation of resident care, the QAPI committee did not maintain documentation of meeting minutes or evidence of monitoring the effectiveness of interventions following a serious safety incident. Staff interviews and observations revealed inconsistent compliance with education and monitoring related to electrical safety, and there was a lack of consistent oversight for electrical devices and power cords used by residents. An event occurred in which a resident was found in bed with third-degree electrical burns after urine contacted an energized power strip positioned in the bed. The resident required transfer to the emergency room for evaluation. Subsequent observations during the survey found ongoing noncompliance, with residents having charging cords in bed or attached to handrails without appropriate care plan interventions. The Maintenance Director confirmed inconsistent monitoring of electrical devices, and the Administrator was unable to provide QAPI meeting minutes or evidence of performance improvement evaluation related to the incident.
Failure to Report Neglect Resulting in Resident Injury
Penalty
Summary
The facility failed to report an incident of neglect with physical harm to the State Survey Agency as required by federal and state law. A resident with paraplegia, neurogenic bladder, and bilateral above-knee amputations, who was cognitively intact and performed self-catheterization, sustained third-degree electrical burns after urine leaked into a power strip that had been placed in the bed. The administrator had previously removed an extension cord from the resident's room and provided a power strip, but there was no documentation of an assessment to ensure the resident could use the power strip safely, nor was there a care plan addressing the safe use of electrical devices or education provided to the resident about the risks involved. Medical records indicated the resident had a history of incontinence and required assistance with personal hygiene and toileting. Despite this, the care plan did not include interventions for intermittent catheterization or address the resident's refusal of care. Staff documented episodes of incontinence, and the resident was known to keep electronics in bed. After the incident, the resident was sent to the emergency room and admitted for treatment of the burns, which covered approximately 4% of the body surface area. Interviews with facility staff, including the former assistant director of nursing, former director of nursing, and the administrator, confirmed that the incident was not reported to the State Survey Agency. Staff also acknowledged that the resident's competency in self-catheterization was not observed or documented, and that no interventions or education regarding the safe use of electrical devices were implemented prior to the incident. The administrator admitted to not reporting the accident as required by regulations.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, in violation of its own policy and federal regulations regarding resident rights to remain in the facility unless specific criteria for discharge are met. The resident in question had a complex medical history, including osteomyelitis, paraplegia, anxiety disorder, and an ileostomy, and was admitted and readmitted to the facility prior to the incident. Documentation showed that the resident experienced an acute episode of confusion, agitation, and combative behavior, which coincided with a urinary tract infection, sepsis, and metabolic encephalopathy. Staff documented that the resident was resistant to care, removed his colostomy bag, and swung a trapeze bar, but interviews with staff indicated that he had not been physically aggressive toward other residents and that his behavior was likely related to his acute medical condition. On the day of the incident, the resident was sent to the hospital for evaluation due to increased confusion and agitation. The facility completed an involuntary discharge notice, citing safety concerns and an inability to meet the resident's needs. The administrator delivered the resident's belongings and attempted to have the resident sign discharge paperwork at the hospital, despite being informed by hospital staff that the resident was not cognitively able to understand or sign the documents. Hospital case management notes and interviews confirmed that the administrator stated the resident would not be allowed to return to the facility, and this was communicated to both the hospital and the resident's family member. Multiple interviews with facility staff, hospital staff, the ombudsman, and the resident himself revealed that the resident was not offered the opportunity to return to the facility after his medical condition stabilized. The administrator maintained that the resident refused to return, but both the resident and his family member stated they were not given the option. The facility's actions were not consistent with its policy or regulatory requirements, as the resident's acute behavioral episode was related to a treatable medical condition, and there was no evidence that the facility could not meet his needs after stabilization.
Neglect Leads to Resident Burns Due to Malfunctioning Hot Water Heater
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in second-degree burns due to a malfunctioning hot water heater in the Station 2 shower room. The resident, diagnosed with paraplegia and requiring substantial assistance for showers, was exposed to scalding water when the hot water heater began gushing hot water and steam onto the floor. Despite multiple reports of the malfunctioning heater, the shower room remained in use, leading to the resident's injury. Staff, including CNAs and LPNs, had repeatedly observed and reported the hot water heater's issues, such as steam and hot water leaking into the shower room. The Director of Nursing and other staff members had informed the Administrator about the problem, but the shower room was not taken out of service. The Administrator instructed staff to manage the situation by turning on a faucet in an adjacent room, rather than addressing the root cause or closing the shower room. The resident, who had no feeling below the waist, was unaware of the scalding water until it caused burns. The incident was preventable, as staff had been aware of the ongoing issues with the hot water heater. The facility's failure to act on these reports and ensure a safe environment for the resident resulted in Immediate Jeopardy and actual harm to the resident.
Resident Burned Due to Hot Water Heater Malfunction
Penalty
Summary
The facility failed to maintain a safe environment for its residents, as evidenced by dangerously high hot water temperatures in the Station 2 shower room. This failure resulted in a vulnerable resident with paraplegia sustaining second-degree burns on the left foot. The incident occurred when the hot water heater malfunctioned, causing scalding water to spray onto the floor where the resident was seated. The water temperature was measured at 169 degrees Fahrenheit at the time of the incident. Interviews and documentation revealed that the facility had been aware of issues with the hot water heater prior to the incident. Staff reported multiple episodes of steam and hot water leaking from the heater, which had been occurring for several months. Despite these warnings, the facility did not take adequate measures to address the problem. The Administrator and Director of Nursing were informed of the malfunctioning heater, but the issue was not resolved, and the shower room continued to be used. The facility's inaction and improper handling of the hot water heater issue led to Immediate Jeopardy, as the malfunction posed a significant risk to resident safety. Staff were instructed to manage the situation by turning on faucets in adjacent rooms to relieve pressure, rather than shutting down the malfunctioning shower room. This inadequate response contributed to the resident's injury and highlighted a lack of effective communication and problem-solving within the facility.
Failure to Address Malfunctioning Equipment Leads to Resident Injury
Penalty
Summary
The facility administration failed to provide adequate oversight and supervision, resulting in a serious incident involving a malfunctioning hot water heater in the Station 2 shower room. Despite being notified of the issue on multiple occasions, the administration did not take appropriate action to address the hazard. The Director of Nursing (DON) and other staff members were aware of the malfunction, which caused scalding hot water to leak onto the floor, yet the shower room continued to be used for resident care. This negligence led to a major burn injury to a resident's left foot, highlighting a significant lapse in ensuring a safe environment. Interviews with staff revealed that the malfunctioning hot water heater had been reported to the Administrator and Maintenance Director prior to the incident. The DON acknowledged receiving a text message about the issue, and Licensed Practical Nurses (LPNs) reported observing steam and hot water leaking from the shower room. Despite these warnings, the Administrator dismissed concerns, suggesting that the water was not hot enough to cause harm and instructed staff to temporarily alleviate the issue by draining hot water from the heater. The Administrator's failure to take decisive action, such as shutting down the malfunctioning shower room, directly contributed to the resident's injury. The facility was cited for Immediate Jeopardy due to this oversight, with deficiencies noted under F-835, F-689, and F-600, indicating substandard quality of care. The report underscores the administration's responsibility to maintain a safe environment and protect residents from neglect and avoidable accidents.
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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