Tri State Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Harrogate, Tennessee.
- Location
- 600 Shawanee Rd, Harrogate, Tennessee 37752
- CMS Provider Number
- 445263
- Inspections on file
- 23
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Tri State Health And Rehabilitation Center during CMS and state inspections, most recent first.
An LPN diverted narcotic medication by signing out extra doses of Hydrocodone-Acetaminophen for a resident without a physician order and taking the medication for personal use. The resident received all scheduled doses and did not experience harm, but the facility failed to prevent the misappropriation, resulting in a deficiency under F-602.
The facility failed to honor a resident's DNR order and did not ensure staff were CPR certified before performing CPR on multiple residents. A resident with a DNR order received CPR due to an EMR update failure. Uncertified staff performed CPR on other residents, revealing a systemic issue in training protocols. Interviews showed staff intended to perform CPR without certification, highlighting a critical compliance gap.
The facility failed to ensure competent nursing staff, leading to CPR being performed against a resident's DNR wishes due to an EMR update failure. Untrained CNAs participated in CPR on multiple residents, highlighting gaps in training and competency verification. Interviews revealed staff were unaware of procedures for verifying code status and performing CPR, with some expressing intent to perform CPR despite not being certified.
The facility's administration failed to honor a resident's DNR order and allowed untrained staff to perform CPR on multiple residents. The administration did not identify or address non-compliance through the QAPI committee, leading to a lack of effective training and oversight. Staff interviews revealed a lack of awareness regarding code status protocols and the location of the code book, resulting in an Immediate Jeopardy situation.
The facility's Governing Body failed to ensure that all nursing staff were educated on CPR processes, leading to untrained CNAs performing CPR on residents, including one whose DNR wishes were not honored. The administration was unaware of these incidents, and many staff were unfamiliar with the code book or its location. The facility also failed to maintain accurate medical records regarding CPR and did not have an effective QAPI program to identify and correct non-compliance.
The facility's QAPI committee failed to address deficiencies related to residents' code status and CPR training, leading to CPR being performed against a resident's wishes and by untrained staff. The committee did not implement effective processes or conduct root cause analyses, resulting in an Immediate Jeopardy situation. Documentation and meeting minutes revealed a lack of action plans and staff education on POST forms and code status protocols.
The facility failed to include code status in the care plans of four residents, despite having physician orders and POST forms indicating their preferences. This oversight was due to a template issue in the electronic medical record system, as confirmed by the MDS Coordinator. The residents had various medical conditions, and the deficiency highlights a failure to adhere to care planning policies.
The facility failed to maintain accurate CPR documentation and code status records for several residents, leading to CPR being performed against a resident's DNR wishes and incomplete documentation of staff participation in CPR events. Some staff involved were not CPR certified, and this was not communicated to the administration.
A deficiency was identified when two residents were involved in an altercation, with one resident blocking the other's doorway and a nurse intervening inappropriately. The residents, both with cognitive impairments and mobility issues, were not protected from abuse, as confirmed by staff interviews and facility investigation.
Misappropriation of Narcotic Medication by LPN
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of narcotic medications. A licensed practical nurse (LPN) signed out additional doses of Hydrocodone-Acetaminophen for a resident who was prescribed this medication for chronic pain related to osteoarthritis, but there was no physician order for extra or PRN doses. The medication administration record showed the resident only received the scheduled doses, and there was no documentation that the resident received the additional doses signed out by the LPN. The resident's pain scores on the relevant days indicated minimal pain, and the resident later reported no concerns regarding pain medication administration. The misappropriation was discovered when a registered nurse (RN) noticed discrepancies during a narcotic count and reported the issue to the Assistant Director of Nursing (ADON). An audit by the Pharmacy Nurse Consultant confirmed that extra doses had been signed out for the resident, but not administered. The LPN admitted to signing out and taking the extra medication for personal use. The facility's policy requires oversight to prevent misappropriation of resident property, but the LPN was able to divert narcotic medication by signing out extra doses without detection until the audit and count revealed the discrepancy. Interviews with staff and review of documentation confirmed that the resident did not miss any scheduled doses and did not experience harm as a result of the incident. The misappropriation was limited to the LPN signing out and diverting narcotic medication intended for the resident, in violation of facility policy and resident rights. The incident was reported to appropriate authorities, and the facility's failure to prevent this misappropriation constituted a deficiency under F-602.
Failure to Honor DNR and Ensure CPR Certification
Penalty
Summary
The facility failed to honor a resident's end-of-life wishes and did not ensure that staff were appropriately trained and certified in CPR before performing CPR on multiple residents. Resident #3, who had a Do Not Resuscitate (DNR) order, was subjected to CPR against their wishes due to a failure in updating the electronic medical record (EMR) with the correct code status. The oversight occurred because the new physician's order from the POST form was not entered into the EMR, leading to the staff performing CPR under the assumption that the resident was a full code. Additionally, the facility did not ensure that staff performing CPR on Residents #8, #9, and #10 were CPR certified. Untrained staff, including CNAs and housekeeping personnel, participated in CPR efforts without the necessary certification, which was a significant oversight in staff training and preparedness. This lack of certification and training was evident in the cases of Resident #8, who was found unresponsive and subjected to CPR by uncertified staff, and Resident #9, where uncertified CNAs performed chest compressions. Similarly, Resident #10 received CPR from a CNA who was not certified, highlighting a systemic issue in the facility's training protocols. Furthermore, interviews with staff revealed that several CNAs and housekeeping staff expressed an intent to perform CPR without adequate training or certification. This intent, coupled with the actual performance of CPR by untrained staff, underscores a critical gap in the facility's compliance with CPR certification requirements. The facility's failure to ensure that only trained and certified staff performed CPR placed residents at risk and demonstrated a lack of adherence to established policies and procedures regarding emergency response and resident rights.
Deficiency in Staff Competency and Code Status Verification
Penalty
Summary
The facility failed to provide competent and proficient nursing staff to ensure resident safety and well-being, particularly in honoring end-of-life wishes and ensuring staff were knowledgeable about code status and CPR. This deficiency was evident when CPR was performed against a resident's wishes due to a failure to update the electronic medical record (EMR) with the resident's DNR status. The resident, who had chronic congestive heart failure and other significant health issues, was subjected to CPR despite having a POST form indicating a DNR preference. The staff involved did not verify the resident's code status before initiating CPR, leading to a breach of the resident's end-of-life wishes. Additionally, the facility failed to ensure that staff performing CPR were appropriately trained and certified. Several CNAs, who were not CPR certified, participated in CPR on multiple residents. These residents had various medical conditions, including chronic respiratory failure, dysphagia, and dementia, and had requested full treatment, including CPR, as per their POST forms. However, the involvement of untrained staff in these critical situations highlighted a significant gap in the facility's training and competency verification processes. Interviews with staff revealed a lack of awareness and training regarding the facility's procedures for verifying code status and performing CPR. Some staff members were unsure of their CPR certification status, and others expressed an intent to perform CPR despite not being certified. The facility's administration was unaware of these deficiencies, indicating a lack of communication and oversight in ensuring that only trained and certified staff performed CPR. This oversight placed residents at risk and demonstrated a failure to adhere to established policies and procedures.
Deficiency in CPR Protocols and End-of-Life Wishes
Penalty
Summary
The facility's administration failed to provide effective leadership and oversight, resulting in a significant deficiency related to the handling of residents' end-of-life wishes and CPR protocols. Specifically, the administration did not honor the end-of-life wishes of one resident, who had a Do Not Resuscitate (DNR) order, and allowed CPR to be performed against the resident's Physician's Order for Scope of Treatment (POST). Additionally, four staff members who were not trained or certified in CPR performed life-sustaining measures on three residents, which was not identified or addressed by the administration. The administration's failure extended to not identifying non-compliance and not developing or implementing effective processes through the facility's Quality Assurance and Performance Improvement (QAPI) committee. The administration did not ensure that staff were adequately trained, even after identifying that CPR was performed on a resident against their DNR status. Furthermore, the administration failed to recognize that non-CPR certified and untrained staff performed CPR on residents and did not take action to educate or implement steps to prevent untrained staff from performing CPR in the future. Interviews with staff revealed a lack of awareness and training regarding the facility's code book, its contents, and the location, as well as the protocols for verifying a resident's code status before performing CPR. The administration did not maintain effective oversight and leadership to identify quality deficiencies, put action steps in place, or have an effective QAPI program to prevent or address patterns of non-compliance. This lack of oversight resulted in an Immediate Jeopardy situation, posing a risk of serious harm to residents.
Failure in CPR Protocols and Oversight
Penalty
Summary
The facility's Governing Body failed to identify non-compliance and implement effective corrective action plans through the facility's Quality Assurance and Performance Improvement (QAPI) program. This failure was evident when the facility did not ensure that all nursing staff, including Certified Nursing Assistants (CNAs), were educated on the Cardiopulmonary Resuscitation (CPR) process. As a result, Resident #3's end-of-life wishes for Do Not Resuscitate (DNR) were not honored, and CPR was performed on three residents by CNAs who were not trained or certified in CPR life-sustaining measures. Additionally, the facility did not identify, educate, and implement action steps when CNAs and Housekeeping Staff, who were not CPR certified, expressed an intent to perform CPR without adequate training. The facility's administration, including the Administrator and the Director of Nursing (DON), were not aware that untrained staff had performed CPR and did not have an effective QAPI program in place to prevent such occurrences. Interviews with staff revealed that many were not familiar with the code book, its contents, or its location, and relied solely on the Electronic Medical Record (EMR) for verification of a code status. The Administrator confirmed that further education and communication were needed to prevent recurrence and acknowledged that the CPR documentation completed after the code events did not contain all the required information on all staff who participated or performed CPR. The Governing Body also failed to maintain effective leadership and oversight related to CPR/DNR or code status protocols. They did not establish and implement policies and procedures to ensure all staff were educated on the code book, its contents, or location, and the likelihood of staff performing CPR when not CPR certified. Furthermore, the facility failed to ensure medical records regarding CPR were complete and accurate for the residents involved, and the Administration did not maintain oversight to ensure an effective QAPI program that identified and corrected non-compliance.
QAPI Committee's Failure to Address CPR and Code Status Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to ensure an effective program that identified and addressed quality deficiencies, particularly concerning residents' code status and end-of-life wishes. The committee did not implement performance improvement activities or conduct a root cause analysis related to staff performing Cardio-Pulmonary Resuscitation (CPR) efforts without proper training or certification. This failure resulted in CPR being performed on a resident against their Physician's Order for Scope of Treatment (POST) and end-of-life wishes, and non-CPR certified staff performing CPR on multiple residents. The QAPI committee did not develop and implement effective processes to train staff after identifying that CPR was performed incorrectly. There was a lack of action plans to correct deficiencies when non-CPR certified and untrained staff performed CPR. Additionally, the committee failed to address the issue of Certified Nursing Assistants (CNAs) and Housekeeping Staff expressing intent to perform CPR without adequate training or certification. This oversight led to an Immediate Jeopardy situation, indicating a high risk of serious injury, harm, impairment, or death to residents. The facility's documentation and meeting minutes revealed that the QAPI committee did not adequately address the issues related to POST forms, advanced directives, or CPR in their meetings. There was no documentation of non-CPR certified staff's intent to perform CPR or the facility's code book, which contained residents' POST forms. Furthermore, there was no evidence that all nursing staff had been educated or in-serviced on the new process for POST forms and the code book, highlighting a significant gap in the facility's quality assurance processes.
Failure to Document Code Status in Care Plans
Penalty
Summary
The facility failed to develop and implement care plans that included the code status for four residents. The interdisciplinary team (IDT) is responsible for creating comprehensive, person-centered care plans based on resident assessments. However, the care plans for Residents #3, #8, #9, and #10 did not include their code status, despite having physician orders and POST forms indicating their preferences. For instance, Resident #3 had a change in code status from CPR/Full Code to Do Not Resuscitate (DNR), but this was not reflected in the care plan. Similarly, Residents #8, #9, and #10 had CPR/Full Code orders that were not documented in their care plans. The deficiency was identified during an audit conducted by the MDS Coordinator, who confirmed that the code status was not entered due to a template issue in the electronic medical record system. The residents involved had various medical conditions, including chronic heart failure, respiratory failure, and Parkinson's disease, with some residents being cognitively intact while others had severe cognitive impairments. The lack of proper documentation of code status in the care plans represents a failure to adhere to the facility's policy and the requirements for comprehensive care planning.
Incomplete CPR Documentation and Code Status Errors
Penalty
Summary
The facility failed to ensure that medical records regarding Cardio-Pulmonary Resuscitation (CPR) were complete and accurate for several residents. For Resident #3, there was a discrepancy between the physician's order and the Tennessee Physician Orders for Scope of Treatment (POST) form regarding the resident's code status. The EMR was not updated to reflect the resident's DNR status, leading to CPR being performed against the resident's wishes. The facility's investigation revealed that the failure to update the EMR was due to staff not entering the new physician's orders from the POST form. For Resident #8, the facility's documentation was incomplete as it did not include all staff members who participated in the CPR event. The nurse's note and the CPR/Code Blue Documentation form failed to document all individuals involved, including some who were not CPR certified. This lack of documentation contributed to the administration's unawareness of untrained staff performing CPR. Similarly, for Residents #9 and #10, the facility's documentation was incomplete, failing to list all staff members who participated in the CPR events. Some staff members involved in the CPR were not CPR certified, and this was not documented or communicated to the administration. The facility's failure to maintain accurate and complete records of CPR events and code statuses led to deficiencies in the care provided to these residents.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a deficiency. Resident #1, who has moderate cognitive impairment and several medical conditions including cerebral infarction and hemiplegia, was involved in an altercation with Resident #2, who has Alzheimer's disease and anxiety disorder. The incident occurred when Resident #2, who uses a wheelchair and has memory problems, blocked the doorway of Resident #1's room. Resident #1 attempted to push Resident #2 back into the hallway, resulting in his hand grazing Resident #2's face. During the incident, RN A intervened by pulling Resident #1 out of the doorway and smacking Resident #2 on the leg. The facility's investigation confirmed the altercation and the actions of RN A. Interviews with staff revealed that Resident #1 is generally not aggressive but can be loud and curse, while Resident #2 is often confused, combative with care, and refuses medications at times. Observations showed Resident #2 moving independently in a wheelchair and interacting with others without noted behaviors. The administrator confirmed the occurrence of the resident-to-resident altercation, highlighting the facility's failure to ensure a safe environment free from abuse for both 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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