Tennessee Veterans Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Murfreesboro, Tennessee.
- Location
- 345 Compton Road, Murfreesboro, Tennessee 37130
- CMS Provider Number
- 445270
- Inspections on file
- 17
- Latest survey
- February 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Tennessee Veterans Home during CMS and state inspections, most recent first.
The facility failed to ensure dumpsters had lids to properly contain refuse and prevent access by rodents or other animals. Despite the facility's policy requiring tight-fitting lids, observations showed trash piled high and dumpsters without lids. Staff continued to dispose of trash in uncovered dumpsters, and the Maintenance Director acknowledged the need for lids and staff retraining.
The facility failed to provide written transfer notices to three residents and their representatives during emergent hospital transfers, as well as to notify the ombudsman. Despite the facility's policy requiring such notifications, residents with Alzheimer's, quadriplegia, and severe cognitive impairment were transferred without the necessary documentation. An LPN confirmed that a Transfer Cover Sheet was supposed to be completed, but this was not done, and the Assistant Director of Clinical Services admitted to the oversight.
The facility failed to provide written bed hold notices to residents or their representatives during hospital transfers, as required by policy. Three residents were transferred to hospitals without receiving these notices, despite the facility's policy allowing bed hold agreements for up to 10 days. Staff interviews revealed inconsistencies in attaching bed hold notices to transfer documents, and the Assistant Director of Clinical Services acknowledged the lack of written notifications due to a unit closure.
A resident with type two diabetes had multiple instances of blood glucose readings exceeding 300 mg/dL, but the facility failed to notify the physician as required by the orders. Despite the facility's policy to consult with the attending physician for treatment changes, the EMR showed no documentation of such notifications. Interviews with staff confirmed the oversight, highlighting a deficiency in care practices.
A dietary staff member failed to follow proper hand hygiene practices by not changing gloves or washing hands after contaminating them while serving food. This occurred twice during food service, and the staff member acknowledged the oversight. The dietary manager confirmed the need for proper handwashing. This deficiency potentially affected 100 of 104 residents consuming food from the facility's kitchen.
The facility failed to protect residents from physical abuse in two incidents. In the first, a resident with moderate cognitive impairment struck another with severe cognitive impairment. In the second, a resident with intact cognition struck another resident multiple times due to impatience. Both incidents were witnessed by staff, and the Director of Nursing confirmed the events.
The facility administration failed to provide adequate oversight and supervision, resulting in deficiencies such as incomplete investigations into major injuries of unknown origin for two residents, inadequate wound care management for multiple residents, and ineffective pain management for a resident with a major injury. Additionally, the administration did not conduct effective QAPI meetings to address quality deficiencies, leading to citations for Immediate Jeopardy and substandard quality of care.
The QAPI committee at the facility failed to effectively identify and address quality deficiencies, resulting in resident neglect, inadequate investigations of adverse events, and ineffective pain management. Despite implementing a Performance Improvement Plan for wound care, the facility did not maintain proper oversight, leading to an increase in wound infections and Immediate Jeopardy citations. The Administrator's involvement was limited, and the previous wound care nurse was unresponsive to feedback.
The facility failed to provide necessary wound care for several residents, resulting in unstageable wounds and infections. Despite having policies and a QAPI plan, the facility did not effectively implement wound care treatments, leading to Immediate Jeopardy. Residents suffered from untreated wounds, some requiring hospital transfers, highlighting significant neglect in care management.
Two residents in a LTC facility sustained serious injuries of unknown origin, but the facility failed to conduct thorough investigations or take appropriate corrective actions. One resident had a tibia fracture, and the other a femur fracture, yet the facility did not follow its policies on abuse and accidents, resulting in a citation for substandard quality of care.
A resident with a history of femur fracture and dementia experienced severe pain for 15 hours without effective management in an LTC facility. Despite complaints of pain, the resident was only given Tylenol, and staff failed to reassess pain levels or evaluate the cause. Delays in obtaining an X-ray and notifying medical staff led to prolonged suffering, resulting in an Immediate Jeopardy citation for substandard care.
The facility failed to report injuries of unknown origin for two residents. One resident with impaired cognition sustained a tibia fracture, and another with severe cognitive impairment suffered a femur fracture. Despite the facility's policy requiring immediate reporting of such injuries, the Administrator did not report them, believing the causes were determined. However, no investigations confirmed the root causes, and the exact circumstances of the injuries remain unknown.
The facility failed to update care plans for three residents following incidents of abuse. One resident was involved in a resident-to-resident incident, while another reported rough handling by CNAs. Despite immediate actions taken, the care plans were not revised to include interventions for these incidents, as confirmed by facility staff.
Two residents in the facility did not receive their scheduled showers and baths, as documented in medical records and confirmed through interviews and observations. One resident, with multiple health conditions, missed numerous scheduled showers over several months, while another resident, with cognitive impairments, received no showers for extended periods. Staffing issues, including high turnover and reliance on agency staff, were cited as contributing factors to the inconsistency in providing scheduled bathing care.
Failure to Properly Cover Dumpsters
Penalty
Summary
The facility failed to ensure that the dumpsters used for trash and cardboard disposal were equipped with lids to properly contain refuse and prevent access by rodents or other animals. The facility's policy, dated 05/13/15, mandates that all garbage and rubbish containers must have tight-fitting lids and be kept covered when not in continuous use. During an initial tour of the kitchen, it was observed that the trash was piled high and not contained within the dumpster, and the dumpsters lacked lids. The Dietary Manager and Maintenance Director confirmed that the dumpsters should not be piled up and should have lids to contain the trash and keep varmints out. Subsequent observations revealed that staff continued to dispose of trash in the dumpsters without lids. On multiple occasions, staff were seen throwing bags of trash into the dumpsters, which remained uncovered. The Maintenance Director acknowledged that the dumpsters should have lids and stated that staff needed retraining. Despite the initial observation and acknowledgment of the issue, the problem persisted, indicating a failure to adhere to the facility's policy on garbage and rubbish disposal.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer notices to three residents and their representatives upon emergent transfers to the hospital, as well as to notify the ombudsman. The facility's policy, titled 'Resident Discharge Policy,' mandates timely and proper notice for any intent to transfer or discharge a resident, including notifying the resident, family, or legal representative, and the ombudsman. However, this policy was not adhered to in the cases of three residents who were transferred to the hospital without receiving the required written notifications. Resident 49, who had a primary diagnosis of Alzheimer's Disease, was transferred to the hospital after becoming unresponsive. Although the family was notified verbally, there was no written transfer notice provided to the resident, their responsible party, or the ombudsman. Similarly, Resident 259, with a primary diagnosis of quadriplegia, experienced multiple unplanned discharges to a short-term general hospital, yet no written notifications were documented in their medical records. The facility's Licensed Practical Nurse (LPN) confirmed that a Transfer Cover Sheet was supposed to be filled out for each hospitalization, but this was not done. Resident 76, who had severe cognitive impairment, was also transferred to the hospital on two occasions without receiving written transfer notifications. The Assistant Director of Clinical Services admitted that the facility was unaware that written notice was required for the family and acknowledged that notifications to the ombudsman had not been completed. This oversight indicates a failure to comply with the facility's own discharge policy and federal or state regulations regarding resident transfers.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide a written bed hold notice to residents or their representatives prior to or within 24 hours of transfer to a hospital, as required by their policy. This deficiency was identified for three residents who were hospitalized. The facility's policy, revised in July 2018, states that a bed hold agreement should be provided for hospital or therapeutic leave, not exceeding 10 days, with the possibility of consecutive agreements. However, the facility did not adhere to this policy for the residents reviewed. For Resident 49, the electronic medical record indicated an unplanned discharge to a short-term general hospital due to a medical emergency. Despite the resident's return to the facility the following day, there was no documentation of a bed hold notification or reserve bed payment information in the resident's records. Similarly, Resident 259 experienced multiple unplanned discharges to a hospital, but the facility failed to provide the required bed hold notifications. Interviews with staff revealed that a Transfer Cover Sheet, which should include a bed hold notice, was supposed to be attached to transfer documents, but this was not consistently done. Resident 76, who had severe cognitive impairment, was also transferred to a hospital on two occasions without receiving a written bed hold notice. The Assistant Director of Clinical Services confirmed that no bed hold notifications were sent in writing to the resident or family, citing the closure of a unit as a reason for not issuing these notices. This lack of compliance with the facility's policy resulted in a deficiency in ensuring residents and their representatives were informed about bed hold procedures during hospital transfers.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to adhere to physician's orders regarding the notification of blood sugar levels exceeding 300 mg/dL for a resident diagnosed with type two diabetes, among other conditions. The facility's policy mandates prompt consultation with the attending physician when treatment alterations are necessary. However, the review of the resident's electronic medical record (EMR) revealed multiple instances where blood glucose readings exceeded 300 mg/dL, yet there was no documentation indicating that the physician was notified as required. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, had several high glucose readings recorded in the Medication Administration Record (MAR) without subsequent physician notification. Interviews with the Unit Manager, Physician Assistant, and Director of Nursing confirmed the oversight, acknowledging that the medical team should have been informed according to the established orders. This lapse in following the physician's orders represents a deficiency in the facility's care practices.
Failure in Hand Hygiene by Dietary Staff
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by dietary staff during food service operations. Specifically, a dietary staff member was observed placing food on trays and running his gloved hand under his nose without changing gloves or washing hands, as required by the facility's dietary policy. This occurred twice during the observation period, and the staff member acknowledged the failure to wash hands when questioned. The dietary manager confirmed that the staff should have removed the gloves and washed hands after each instance of contamination. This deficiency had the potential to affect 100 of 104 residents who consumed food prepared in the facility's kitchen.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse during two separate incidents involving three residents. In the first incident, a resident with moderate cognitive impairment struck another resident with severe cognitive impairment on the hand when the latter attempted to move the former's wheelchair. This incident was witnessed by a Certified Nurse Technician who reported it to the Nursing Manager. The Director of Nursing confirmed the incident during an interview, stating it occurred while the resident was preparing for an appointment. In the second incident, a resident with intact cognition physically struck another resident with severe cognitive impairment multiple times on the back. This occurred as the two residents were exiting the dining room, with the aggressor becoming impatient with the slower-moving resident in front. The incident was witnessed by a Certified Nurse Aide who intervened and noted the victim appeared scared. The Director of Nursing and the aggressor both provided accounts of the incident, with the aggressor denying the severity of the actions despite video evidence.
Facility Administration Fails in Oversight and Supervision
Penalty
Summary
The administration of the facility failed to provide adequate oversight and supervision, leading to several deficiencies. Specifically, the administration did not ensure thorough investigations were conducted to determine the root cause of major injuries of unknown origin for two residents. The investigation into one resident's injury was incomplete, as the administrator did not review camera footage or obtain statements from all involved staff. Additionally, the administration did not implement any training regarding resident transfers following the incident. The administration also failed to ensure that physician's orders for wound care were followed for multiple residents. The Director of Nursing (DON) acknowledged missed documentation and identified that wound care treatments were not being performed on weekends. Despite recognizing this issue, the DON was not present on weekends and was denied the request for a weekend treatment nurse. This lack of oversight resulted in inadequate wound care management for several residents. Furthermore, the administration did not ensure effective pain management for a resident who sustained a major injury and experienced unresolved severe pain. The administration also failed to conduct effective Quality Assurance Performance Improvement (QAPI) meetings to address identified quality deficiencies. The administrator's involvement in QA discussions was limited, and there was no comprehensive monitoring to ensure wound care was completed. These failures contributed to the facility being cited for Immediate Jeopardy and substandard quality of care.
QAPI Committee's Failure Leads to Immediate Jeopardy
Penalty
Summary
The Quality Assurance Performance Improvement (QAPI) committee at the facility failed to ensure an effective program that identified and addressed quality deficiencies, leading to significant issues such as resident neglect, inadequate investigations of adverse events, and ineffective pain management. The facility's policies and procedures were not properly implemented or overseen, resulting in a situation of Immediate Jeopardy, where the noncompliance was likely to cause serious harm to residents. The facility was cited for Immediate Jeopardy at several F-tags, indicating substandard quality of care. The facility's QAPI program did not effectively address the increasing number of wound infections, despite implementing a Performance Improvement Plan (PIP) to tackle issues with pressure ulcers and inconsistent treatment plans. The QAPI committee's oversight was insufficient, as evidenced by the lack of proper investigation into major injuries of unknown origin and the failure to establish an effective pain management program. Interviews with staff revealed that the previous wound care nurse was not receptive to feedback, and the Administrator's involvement in monitoring wound care was limited to discussions and reviewing reports. The facility's failure to maintain oversight and implement necessary policies and procedures resulted in neglect for residents requiring wound care and inadequate investigation of adverse events. The QAPI committee did not ensure that the facility was administered efficiently, leading to ongoing Immediate Jeopardy. The facility's census at the time of the survey was 114, and the deficiencies were identified during a partial extended survey conducted on May 15, 2024.
Neglect in Wound Care Management
Penalty
Summary
The facility failed to ensure that all residents were free from neglect, specifically in providing necessary wound care for five residents. Resident #7 did not receive wound care as ordered by the physician for a wound that progressed from excoriation to an unstageable wound. Similarly, Resident #9 did not receive wound care for a right calf wound and a right heel wound, both of which progressed to unstageable wounds. Resident #12 also did not receive wound care for a left calf wound, which required antibiotics and hospital transfer. Resident #13 did not receive wound care for a right heel wound, and the facility failed to identify and treat additional unstageable wounds on the resident's ischium. Resident #14 did not receive treatment for a diabetic ulcer on the right second toe, which became infected and required hospital transfer for amputation. These failures resulted in Immediate Jeopardy, indicating a situation where the provider's noncompliance likely caused serious harm to the residents. The facility's policies on abuse, neglect, and pressure ulcer management were not effectively implemented, as evidenced by the lack of documentation and follow-through on wound care treatments. The Quality Assurance Performance Improvement (QAPI) plan and meeting minutes revealed ongoing issues with wound care management, including staffing turnover and missing documentation. Despite a performance improvement plan being in place, the facility experienced an increase in wound infections over several months.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to conduct thorough investigations and take appropriate corrective actions for two residents with injuries of unknown origin, resulting in an Immediate Jeopardy situation. Resident #9, who had a right displaced tibia fracture, was found to have a swollen and bruised leg, but the facility could not provide documentation of a complete investigation into the cause of the injury. Interviews with staff revealed that the resident was non-verbal and had impaired mobility, making it unlikely that the injury was self-inflicted. Despite these findings, the facility did not conduct a thorough investigation or interview all relevant staff members. Similarly, Resident #10 sustained a subtrochanteric right femur fracture, and the facility again failed to conduct a comprehensive investigation. The resident had severely impaired cognition and required assistance for transfers, yet the facility did not involve the CNAs assigned to the resident in the investigation process. The Administrator admitted to not reviewing camera footage or obtaining statements from all staff involved, leaving the cause of the injury undetermined. The facility's policies on abuse, neglect, and accidents were not followed, as evidenced by the lack of documentation and incomplete investigations for both residents. The failure to adhere to these policies and procedures resulted in a citation for substandard quality of care, with a scope and severity level of J, indicating a serious deficiency that posed a risk of harm to the residents.
Failure in Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement an effective pain management regimen for a resident who was cognitively impaired and vulnerable, resulting in the resident experiencing moderate to severe pain for approximately 15 hours before being transferred to the hospital. The resident, who had a subtrochanteric right femur fracture, was given Tylenol for severe pain but did not receive adequate follow-up or assessment to determine the cause of the pain. The facility's policy required a comprehensive pain assessment and timely intervention, which was not adhered to in this case. The medical record review revealed that the resident had a history of a right femur fracture and dementia, with a BIMS score indicating severely impaired cognition. Despite the resident's complaints of severe pain, the nursing staff did not reassess the pain level or evaluate the effectiveness of the administered Tylenol. The resident's pain was not adequately managed, and there was a lack of documentation regarding the evaluation of the pain's cause and the effectiveness of the pain relief measures. Interviews with facility staff indicated that there was a delay in obtaining an X-ray and initiating appropriate pain management interventions. The nursing staff failed to notify the nurse practitioner or medical director in a timely manner to address the resident's severe pain and potential injury. The facility's inaction and lack of adherence to its pain management policy resulted in the resident experiencing prolonged pain and necessitated an Immediate Jeopardy citation for substandard quality of care.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin to the State Survey Agency for two residents. Resident #9 sustained a right displaced tibia fracture, and Resident #10 sustained a subtrochanteric right femur fracture. Both injuries were identified during routine care, but the facility did not report them as required by their policy. The facility's policy mandates immediate reporting of such injuries to the Administrator and subsequent reporting to the Department of Health within prescribed timeframes. Resident #9, who has moderately impaired cognition and requires extensive assistance for locomotion, was found with a swollen right lower leg and bruising on the left upper arm. An X-ray confirmed a mild fracture of the tibia. Despite the injury's unknown origin, the Administrator did not report it, believing the cause was determined within two hours. However, no investigation was provided to confirm the root cause of the injury. Resident #10, with severely impaired cognition and dependent on assistance for transfers, was found with a right hip fracture of unknown origin. The Administrator and the previous Interim DON speculated the injury occurred during a transfer but did not involve the CNAs in the investigation or review camera footage. The exact cause of the injury remains unknown, and the facility did not report it as required.
Failure to Update Care Plans Following Abuse Incidents
Penalty
Summary
The facility failed to revise the comprehensive care plans to include interventions for abuse for three residents following incidents of abuse. Resident #3, who was admitted with diagnoses including unspecified dementia and Alzheimer's disease, was involved in a resident-to-resident incident where Resident #21 hit her with a foam pool noodle. Despite the incident being reported and immediate actions taken, the care plan for Resident #3 was not updated to include interventions for this abuse. Similarly, Resident #21, who has Alzheimer's disease and cognitive impairment, did not have her care plan revised to address the incident. Resident #4, admitted with conditions such as atherosclerotic heart disease and major depressive disorder, reported an incident involving rough handling by three CNAs during a catheter adjustment. The CNAs were suspended and removed from the facility, but the care plan for Resident #4 was not updated to reflect this employee-to-resident abuse. Interviews with facility staff, including the MDS Coordinator and the Social Service Director, confirmed that the care plans should have been updated following these incidents, but this was not done.
Failure to Provide Scheduled Showers and Baths
Penalty
Summary
The facility failed to ensure that two residents received their scheduled showers and baths, as evidenced by the review of facility policies, medical records, observations, and interviews. Resident #1, who was admitted with multiple diagnoses including Atherosclerotic Heart Disease and Type 2 Diabetes Mellitus, was scheduled to receive showers three times a week. However, documentation revealed significant gaps in bathing care, with Resident #1 missing scheduled showers and bed baths for multiple consecutive days across several months. Interviews with Resident #1 and family members highlighted ongoing issues with personal hygiene care, including infrequent showers and inadequate assistance with shaving. Resident #14, diagnosed with conditions such as Cerebral Infarction and Vascular Dementia, was also scheduled for regular showers. However, the documentation showed that Resident #14 received no showers for extended periods, relying instead on bed baths. Observations noted that Resident #14 appeared unkempt, with disheveled hair and dirty nails, indicating a lack of proper hygiene care. Interviews with family members and staff further corroborated the inconsistency in providing scheduled bathing care. The facility's failure to provide scheduled showers and baths was attributed to staffing issues, including high turnover and reliance on agency staff, which affected the continuity of care. Interviews with various staff members, including the Director of Nursing and the Quality Assurance nurse, acknowledged the challenges in maintaining consistent bathing schedules and documentation. Despite recognizing the issue, there was a lack of documented follow-up or corrective actions to address the deficiency in providing adequate personal hygiene care to the residents.
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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