Towne Square Care Of Puryear
Inspection history, citations, penalties and survey trends for this long-term care facility in Puryear, Tennessee.
- Location
- 220 College Street, Puryear, Tennessee 38251
- CMS Provider Number
- 445470
- Inspections on file
- 15
- Latest survey
- March 26, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Towne Square Care Of Puryear during CMS and state inspections, most recent first.
The facility was found to have unsanitary conditions in the kitchen and medication room, with a dark slimy buildup in the ice machine and a yellow sticky substance in the nourishment refrigerator. The Certified Dietary Manager and a Registered Nurse confirmed that these conditions should not be present, indicating a failure to adhere to the facility's sanitization policy.
A facility failed to develop an elopement risk care plan for a resident with moderate cognitive impairment and multiple diagnoses. Despite a policy requiring care plans to be updated based on residents' needs, the resident's care plan lacked interventions for elopement risk. An incident occurred when the resident was found outside in the parking lot, attempting to go home. The DON confirmed the resident was an elopement risk and should have had a care plan to address this.
The facility failed to document communication with a hospice provider for a resident, as required by policy, and did not follow physician orders for routine lab tests for another resident. The DON confirmed the absence of a hospice documentation process and acknowledged that required labs were not conducted, highlighting lapses in communication and adherence to medical directives.
Two residents in the facility had unsecured hazardous items, such as nail polish and lotions labeled 'keep out of reach of children,' in their rooms. Both residents were cognitively intact and required supervision. An LPN was unsure about the policy for these items, and the DON confirmed they should be secured. Another LPN confirmed that nail polish and remover should be stored in a locked medication cart or room.
The facility failed to post complete daily staff information, including the total number of staff and actual hours worked by licensed staff responsible for resident care, for 20 out of 24 sampled days. The facility's policy requires daily posting of this information to ensure proper staffing according to regulations. The DON confirmed the missing documentation and inaccuracies in the forms.
A facility failed to maintain a medication error rate below 5%, with two errors observed. One resident received Omeprazole at an incorrect time, and another received an incorrect dosage of Folic Acid. RN A did not follow the prescribed orders, leading to these errors.
The facility failed to secure medications properly, as a medication cart was left unlocked and unattended, and a resident's room contained unsecured cough drops. An LPN confirmed that the cart should be locked and that no residents were assessed to self-administer medications.
The facility failed to follow infection control practices during medication administration. An LPN used contaminated gloves to clean a glucometer, and an RN did not disinfect a blood pressure cuff between residents. Additionally, the RN administered a dropped medication tablet to a resident without replacing it.
The facility failed to maintain sanitary conditions in the kitchen, with observations of dirty equipment, carbon build-up on pans and grills, and disrepair in kitchen cabinets. The Dietary Manager and Administrator acknowledged the issues, which could potentially affect all 25 residents receiving meal trays from the kitchen.
The facility failed to report allegations of abuse to APS, the Ombudsman, and local law enforcement for three residents. One resident reported inappropriate touching by another resident, and another reported being hit by a staff member. The facility did not complete required 5-day follow-up reports to the state agency.
A resident with severe cognitive impairment and a history of falls experienced an unwitnessed fall resulting in a head injury. Despite the facility's policy requiring neuro checks for 72 hours post-incident, no neuro checks were conducted. The Director of Nursing confirmed the absence of these checks in the resident's medical record.
The facility failed to ensure there was an RN on duty for 8 consecutive hours a day, 7 days a week for 4 days reviewed. There was no RN scheduled or documented as having worked for 8 consecutive hours on these days, as confirmed by the DON.
The facility failed to maintain an adequate supply of over-the-counter medications, specifically Mucinex and Omeprazole, affecting a resident who did not receive these medications on multiple occasions. The RN and Administrator confirmed the lack of stock and issues with medication procurement.
Unsanitary Conditions in Kitchen and Medication Room
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as evidenced by observations of unsanitary conditions in the ice machine and nourishment refrigerator. During a kitchen inspection, a dark slimy buildup was found inside the ice machine. The Certified Dietary Manager confirmed that such a buildup should not be present. Additionally, in the medication room, the nourishment refrigerator was found to have a yellow sticky substance in both the freezer and on the second shelf of the refrigerator. A Registered Nurse confirmed that there should not be any yellow substance present in these areas. These observations indicate a failure to adhere to the facility's policy on sanitizing food storage areas and equipment, which requires that all equipment be cleaned and sanitized regularly.
Failure to Develop Elopement Risk Care Plan
Penalty
Summary
The facility failed to develop an elopement risk care plan for a resident who was identified as having moderate cognitive impairment and multiple diagnoses, including Impulse Disorder, Paranoid Schizophrenia, Dementia, and Anxiety. The facility's policy on care planning, dated February 1, 2017, mandates that care plans be developed, implemented, and updated based on residents' needs and any changes that occur during their stay. Despite this policy, the care plan for the resident, dated December 29, 2024, did not include any focus, problems, or interventions related to elopement risk. An incident occurred on February 2, 2025, when the resident was found outside the facility in the parking lot in her wheelchair, attempting to go home. This incident was documented in a nurse's note and an incident report, both dated February 2, 2025. During an interview on March 25, 2025, the Director of Nursing confirmed that the resident's exit from the building classified her as an elopement risk and acknowledged that a care plan should have been developed to address this risk and prevent future occurrences.
Deficiencies in Hospice Communication and Adherence to Physician Orders
Penalty
Summary
The facility failed to establish a documented communication process between the long-term care facility and the hospice provider, as required by their policy and the Nursing Facility Hospice Agreement. This deficiency was identified in the case of a resident who was admitted to hospice care. The Director of Nursing (DON) confirmed that there was no designated place for hospice to document their visits and notes, which is contrary to the facility's policy that mandates all communications between the hospice and the nursing facility to be documented in the resident's clinical record. This lack of documentation could potentially lead to unmet resident needs and preferences at the end of life. Additionally, the facility did not adhere to physician orders for another resident who was supposed to have routine lab tests conducted at specified intervals. Despite the orders for regular lab tests, the resident had not received any labs since admission, which was confirmed by the DON. The failure to conduct these labs as ordered indicates a lapse in following physician directives, which is essential for monitoring and managing the resident's health conditions, including diabetes, hypertension, and the use of various medications.
Unsecured Hazardous Items Found in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe and secure environment for residents, as evidenced by the presence of hazardous items in the rooms of two residents. Resident #18, who was cognitively intact and required supervision with activities of daily living, had several unsecured items in their room, including nail polish and various lotions labeled 'keep out of reach of children.' These items were observed on the dresser and bedside table during medication administration. When questioned, an LPN was unsure about the policy regarding these items and deferred to the Director of Nursing, who later confirmed that such items should be secured and away from residents. Similarly, Resident #22, also cognitively intact and requiring supervision, had unsecured nail polish and nail polish remover on their bedside table. An LPN confirmed that these items should be stored in a locked medication cart or medication room, away from residents. The presence of these unsecured hazardous items in resident rooms indicates a failure to adhere to the facility's policy of maintaining a hazard-free environment.
Incomplete Daily Staff Postings
Penalty
Summary
The facility failed to comply with its policy on daily staff postings, as evidenced by the incomplete documentation of the total number of staff and actual hours worked by licensed staff responsible for resident care. This deficiency was observed in the facility's Daily Staff Posting forms for 20 out of 24 sampled days between March 1, 2025, and March 24, 2025. The facility's policy, dated February 1, 2017, mandates the daily posting of resident census and staffing information to ensure proper licensed nursing staff are provided according to regulations. During an interview on March 25, 2025, the Director of Nursing confirmed the missing documentation and acknowledged the inaccuracy of the forms.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to ensure that medications were administered with a medication error rate of less than 5%, as evidenced by two observed errors out of 26 opportunities, resulting in a medication error rate of 7.69%. The first error involved a resident with diagnoses including Anxiety, Chronic Pain Syndrome, Hypertension, GERD, and Asthma. The resident was cognitively intact with a BIMS score of 15. A physician's order required Omeprazole 20mg to be administered before breakfast at 5 AM. However, RN A administered the medication at 8:46 AM, which was not in accordance with the prescribed time, constituting a medication error. The second error involved another resident with diagnoses including Dysphagia, Cognitive Communication Deficit, Depression, Drug Induced Myopathy, Hypertension, and Weakness. This resident was moderately cognitively impaired with a BIMS score of 11. The facility's order summary indicated that the resident was to receive 1mg of Folic Acid daily. During medication administration, RN A administered two 400 mcg tablets of Folic Acid, totaling 800 mcg, which was less than the prescribed 1mg. RN A acknowledged the error and admitted that she should have consulted the Director of Nursing or the physician for further instructions due to the unavailability of the correct dosage.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly stored and secured, as evidenced by an unsecured and unattended medication cart and unsecured medications in a resident's room. The facility's policy on medication storage, dated February 1, 2017, mandates that medications and biologicals be stored in a safe and secure manner, with compartments locked when not in use. However, observations revealed that the Short Hall Medication Cart was left unlocked and unattended at the Nurses' Station, with no licensed nursing staff present. During an interview, an LPN confirmed that the medication cart should be locked at all times when not in use. Additionally, in the room of a resident with diagnoses including anxiety, chronic pain syndrome, hypertension, and asthma, a bag of cough drops was found unsecured and unattended on the bedside table. The resident was cognitively intact and required moderate assistance with activities of daily living. An LPN confirmed that the cough drops should have been locked on the medication cart or in the medication room, as no resident in the facility had been assessed to self-administer medications. These findings indicate a failure to adhere to the facility's medication storage policy, compromising the security of medications.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration, as observed with two nurses. One nurse, identified as LPN C, was seen cleaning a glucometer machine with gloves that had been contaminated by reaching into a trash can to retrieve a cleaning cloth package. LPN C did not change gloves or re-clean the glucometer after this action, which is against the facility's hand hygiene policy that requires hand hygiene after handling potentially contaminated items. Another nurse, RN A, failed to clean reusable resident equipment between uses. RN A used a blood pressure cuff on one resident and then another without disinfecting it in between, contrary to the facility's policy on disinfecting resident equipment. Additionally, RN A dropped a medication tablet on a resident's chest, picked it up with bare hands, and administered it to the resident, acknowledging later that the tablet should have been discarded and replaced. These actions were confirmed by RN A during an interview, admitting to not following the required disinfection and medication administration protocols.
Unsanitary Conditions in Kitchen
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served under sanitary conditions. Observations revealed multiple instances of unsanitary conditions in the kitchen, including a dirty trash can, carbon build-up on pans, dirty equipment, and a deep fryer with food particles and carbon build-up. Additionally, the flat grill had significant carbon build-up, and the kitchen cabinets were in disrepair with peeling Formica laminate and dark furry stains, possibly mold, under the sink. The cabinet under the sink also had an old stained cloth and a caved-in floor with a torn back wall. These observations were made over several days and confirmed through interviews with the Dietary Manager (DM) and the Administrator, who acknowledged the unsanitary conditions and the need for reeducation and replacement of certain items. The facility's policies and cleaning schedules were reviewed, revealing that the food service area should be maintained in a clean and sanitary manner, with specific cleaning tasks assigned weekly and monthly. However, the DM admitted that certain cleaning tasks, such as removing carbon build-up from pans and cleaning the deep fryer, had been overlooked. The DM also confirmed that the trash cans, ovens, and other equipment should not have the observed build-up and stains. The Administrator agreed that the kitchen cabinets needed replacement and that the mold-like stains and disrepair under the sink were unacceptable. The facility had a census of 25 residents, all of whom received meal trays from the kitchen, indicating that the unsanitary conditions could potentially affect all residents.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse to the appropriate authorities, including Adult Protection Service (APS), the Long-Term Care Ombudsman, and local law enforcement, for three residents. Resident #8, who was severely cognitively impaired, was involved in an incident where he allegedly touched Resident #17 inappropriately. Despite the investigation, which included assessments and interviews, the facility did not report the incident to the police and failed to complete a 5-day follow-up report to the state agency. The Director of Nursing and the Administrator confirmed these lapses during interviews. Resident #177, who was moderately cognitively impaired, reported being hit by a staff member. The Administrator conducted an investigation, including interviews and assessments, but did not report the allegation to the police, APS, or the Ombudsman. Additionally, the facility did not complete a 5-day follow-up report to the state agency. These failures to report and follow up on allegations of abuse were confirmed by the Administrator during an interview.
Failure to Conduct Neurological Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure neurological checks were obtained after an unwitnessed fall with a head injury for a resident. The facility's policy required neuro checks to be performed for a 72-hour period following such incidents. However, a review of the medical record revealed that no neuro checks were conducted for the resident after the fall on 3/27/2024, which resulted in a hematoma and bruising to the left side of her face. The Director of Nursing confirmed the absence of neuro checks in the resident's medical record during an interview on 4/3/2024. The resident, who was admitted with diagnoses including Dementia, Osteoarthritis, and a history of Malignant Neoplasm of the Uterus, was assessed as severely cognitively impaired and at risk for falls. The fall incident report indicated that the resident was found on the bathroom floor with a hematoma to her left outer brow and a skin tear on her left hand. Despite these injuries, the facility did not perform the required neuro checks, as confirmed by the Director of Nursing. Observations on subsequent days noted the resident still had significant bruising and discoloration on her face.
Failure to Ensure RN Coverage for 8 Consecutive Hours Daily
Penalty
Summary
The facility failed to ensure there was a Registered Nurse (RN) on duty for 8 consecutive hours a day, 7 days a week for 4 of 29 days reviewed. Specifically, on 10/8/2023, 11/5/2023, 11/11/2023, and 11/26/2023, there was no RN scheduled or documented as having worked for 8 consecutive hours. This was confirmed through a review of the facility's policy, nurse schedules, group hours report, and time sheets. The Director of Nurses (DON) also confirmed the lack of RN coverage on these dates during an interview on 4/3/2024.
Failure to Maintain Adequate Supply of Over-the-Counter Medications
Penalty
Summary
The facility failed to maintain an adequate supply of over-the-counter medications, specifically Mucinex and Omeprazole, for three medication carts. The facility's policy required supplies to be ordered from an approved medical vendor and maintained in the stock room, with orders placed at least monthly or more frequently if needed. Despite this policy, the facility was out of Mucinex and Omeprazole for at least a week, as confirmed by a Registered Nurse (RN) and the Administrator. The RN noted that the facility had been experiencing problems with medication procurement for the last month or two, and the Administrator admitted to not saving order sheets after placing orders, which contributed to the issue. Resident #7 was directly affected by this deficiency, as documented in the Electronic Medication Administration Record (EMAR) and Medication Administration Record (MAR). The resident did not receive Mucinex on multiple occasions over several months, and during an observation, the RN confirmed that the resident's medication cup did not contain Mucinex or Omeprazole due to the lack of stock. Interviews with the RN and the Administrator revealed that the facility had not taken alternative measures, such as purchasing the medications from a local retail store, to ensure the availability of these essential medications for 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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