Weakley Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dresden, Tennessee.
- Location
- 700 Weakley County Nursing Home Road, Dresden, Tennessee 38225
- CMS Provider Number
- 445437
- Inspections on file
- 19
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Weakley Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to maintain safe hot water temperatures, with readings between 122.5 and 130 degrees Fahrenheit in several rooms, posing a risk to residents. Additionally, inadequate fall prevention measures led to multiple falls for a resident with severe cognitive impairment, resulting in a serious injury. The Maintenance Director's failure to document and communicate water temperature issues, along with insufficient fall interventions, contributed to the deficiencies.
A resident with a history of severe cognitive impairment and aggressive behaviors struck another resident, causing harm. The facility failed to implement effective interventions or a care plan to manage the aggressive resident's behaviors, leading to the incident. Staff acknowledged that more could have been done to ensure safety.
The facility failed to secure medications properly, as two medication carts were left unlocked and unattended during administration. An LPN left a cart unlocked while retrieving items and answering a call, and another cart was found unattended in a hallway. The DON confirmed this was against policy.
The facility administration failed to monitor hot water temperatures, resulting in dangerously elevated levels in resident rooms. Additionally, inadequate supervision led to falls and injuries among residents, with one resident sustaining a fracture. The facility also failed to prevent resident-to-resident abuse and did not provide appropriate care for a resident with behavioral issues, resulting in harm to another resident.
A resident with severe cognitive impairment was found with a self-release seat belt that functioned as a restraint, as she was unable to unlatch it independently. The facility's policy requires that restraints be used only in emergencies and with proper documentation, which was not present in this case. The DON confirmed the resident's inability to release the belt classified it as a restraint, and acknowledged the lack of necessary orders and documentation.
A facility failed to investigate and report an alleged employee-to-resident abuse incident involving a resident with respiratory failure, depression, and dementia. The incident was not reported immediately, and no incident report was completed. The Sheriff's Department found insufficient evidence for further investigation, and the facility did not notify Adult Protective Services. Interviews revealed the investigation was incomplete, highlighting deficiencies in the facility's response to the abuse allegation.
The facility failed to complete baseline care plans within 48 hours for two residents, as required by policy. Both residents had initiated care plans that were left unsigned by the resident or family, resulting in incomplete documentation. The MDS Coordinator confirmed the lack of signatures, indicating non-compliance with the facility's policy.
A resident with a history of vascular dementia and behavioral disturbances was admitted to an LTC facility, where they exhibited challenging behaviors such as wandering, entering other residents' rooms, and displaying sexually inappropriate actions. Despite being prescribed medications for agitation and anxiety, the facility failed to implement effective interventions, leading to ongoing safety concerns. Staff interviews revealed inadequate communication and follow-up, with the DON acknowledging insufficient measures to ensure safety.
An LPN at the facility failed to properly reconcile controlled medications, specifically Lorazepam, for two residents. The facility's policy requires nurses to complete the Controlled Substance Inventory Record and maintain a running count of medications. However, discrepancies were found in the medication counts for residents with various diagnoses, including Dementia and Parkinson's Disease. The LPN admitted to not signing out the medications, and the DON confirmed the issue.
The facility did not update its Three-Day Disaster Menu to match the actual 3-Day Emergency Food Supply. The menu listed peanut butter and protein bars, but these items were missing from the emergency stock. The Dietary Supervisor and a Registered Dietician confirmed that listed items should be present in the supply.
An LPN failed to follow Enhanced Barrier Precautions during wound care for a resident with an unstageable pressure injury. The LPN did not wear a gown and used a contaminated dressing, contrary to the facility's policy requiring gowns and gloves for high-contact activities. The resident had multiple diagnoses, including dementia and malnutrition, and was severely cognitively impaired.
The facility failed to maintain safe hot water temperatures, with readings between 122.5 and 130 degrees Fahrenheit in several resident rooms, exceeding state regulations. This posed a risk to residents, especially those who were cognitively or physically impaired. Additionally, the facility did not provide adequate fall prevention measures, leading to multiple falls for a resident with severe cognitive impairment, resulting in injuries. The Maintenance Director adjusted the water heater without proper documentation or notification, and the Administrator was not adequately informed, contributing to the deficiencies.
A resident with a history of aggressive behaviors harmed another resident by hitting them with a plastic cup, causing lacerations. The facility's interventions, including medication and redirection, were ineffective in managing the aggressive resident's behaviors, and no care plan was in place prior to the incident. Staff interviews indicated that the facility did not implement adequate measures to ensure the safety of residents and staff.
The facility failed to secure medications properly, as two medication carts were left unlocked and unattended during administration. An LPN left a cart unlocked while retrieving a computer mouse and answering a phone call, and another cart was found unlocked in a hallway. The DON confirmed that carts should not be left unattended, highlighting a breach in policy.
The facility administration failed to monitor and prevent dangerously elevated hot water temperatures, leading to potential harm for residents. Additionally, inadequate supervision and fall risk assessments resulted in injuries, including a fracture. The facility also failed to prevent resident-to-resident abuse and did not provide effective care for a resident with behavioral issues, resulting in harm. Communication lapses and insufficient interventions were noted by the DON.
A resident with severe cognitive impairment was found unable to release a self-release seat belt, which was used without a physician's order, contrary to the facility's restraint-free policy. Despite initial claims by the DON that the resident could release the belt, observations confirmed the resident's inability to do so, indicating a failure to adhere to the facility's policy.
A facility failed to investigate an alleged employee-to-resident abuse incident involving a cognitively impaired resident. The incident was not reported immediately, and the investigation lacked necessary documentation, including an incident report and notification to Adult Protective Services. Interviews with the Administrator and DON confirmed the investigation was incomplete.
The facility failed to complete baseline care plans within 48 hours for two residents, as required by policy. Both residents had initiated care plans that were left unsigned by the resident or family, resulting in non-compliance with the facility's policy. Interviews confirmed the oversight, highlighting a lapse in adhering to the required timeframe for care plan completion.
A resident with a history of dementia and behavioral disturbances was admitted to an LTC facility, where they exhibited aggressive and inappropriate behaviors. Despite being prescribed medications, the facility failed to implement effective non-pharmacological interventions or adjust the care plan to manage these behaviors. Staff interviews revealed a lack of awareness and documentation, and the DON admitted that interventions were likely insufficient to ensure safety.
An LPN failed to properly reconcile controlled medications, as required by facility policy, by not signing out medications on the Controlled Substance Inventory Record and not maintaining a running count. Discrepancies were found in the Lorazepam counts for two residents, with the LPN admitting to not signing out the medications. The DON confirmed the necessity of matching controlled counts with actual pill counts.
The facility did not update its Three-Day Disaster Menu to match the actual emergency food supply. Policies required a 3-to-7-day supply of nonperishable foods, but items like peanut butter and protein bars were missing. The Dietary Supervisor and a Registered Dietician confirmed that listed items should be present in the emergency stock.
An LPN failed to follow Enhanced Barrier Precautions during wound care for a resident with an unstageable pressure injury. The LPN did not wear a gown and used a contaminated dressing, contrary to the facility's policy requiring gowns and gloves for high-contact care activities. The resident had multiple diagnoses, including dementia and malnutrition, and was severely cognitively impaired.
Unsafe Hot Water Temperatures and Inadequate Fall Prevention
Penalty
Summary
The facility failed to maintain a safe environment by not ensuring that hot water temperatures in resident rooms were within the safe range of 105 to 115 degrees Fahrenheit, as required by state licensure regulations. On multiple occasions, dangerously elevated hot water temperatures ranging from 122.5 to 130 degrees Fahrenheit were recorded in several resident rooms. This failure placed residents, particularly those who were cognitively or physically impaired, at risk of serious harm. The Maintenance Director admitted to adjusting the water heater to a higher temperature without adequately monitoring or documenting the changes, leading to the unsafe conditions. Additionally, the facility did not provide adequate supervision and interventions to prevent falls among residents. Resident #11, who was severely cognitively impaired and had a history of falls, experienced multiple falls resulting in a serious injury—a closed fracture of the left distal femur. Despite the resident's known fall risk, the facility's interventions were insufficient and inconsistently implemented, as evidenced by the lack of timely and effective measures to prevent further falls. The facility's Fall Committee meetings and care plan revisions did not result in effective strategies to mitigate the resident's fall risk. The facility's leadership, including the Administrator and Maintenance Director, failed to communicate and address the issues effectively. The Administrator was not informed of the dangerously high water temperatures or the adjustments made to the water heater. Furthermore, the Maintenance Director did not document or report the water temperature issues or the corrective actions taken, leading to ongoing noncompliance with safety standards. The lack of communication and documentation contributed to the facility's inability to ensure a safe environment for its residents.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in actual harm. Resident #42 sustained two lacerations to the forehead when Resident #166 struck him with a hard plastic drinking cup. The facility's policies on abuse prevention and resident abuse were not effectively implemented, as Resident #166's aggressive behaviors were not adequately managed or documented prior to the incident. Resident #166 had a history of severe cognitive impairment and aggressive behaviors, including wandering, entering other residents' rooms, and physical aggression towards staff and other residents. Despite being on medications for agitation and anxiety, these interventions were ineffective in controlling his behaviors. The facility did not have a care plan in place for Resident #166's behaviors before his discharge, indicating a lack of proactive measures to address his known behavioral issues. Interviews with staff revealed that interventions to manage Resident #166's behaviors were insufficient. The Director of Nursing acknowledged that more could have been done to ensure the safety of residents and staff. The lack of one-on-one supervision and inadequate behavioral interventions contributed to the incident where Resident #166 harmed Resident #42, highlighting a significant deficiency in the facility's ability to protect residents from abuse.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure medications were properly stored and secured, as evidenced by two incidents involving medication carts being left unlocked and unattended. The facility's policy mandates that all medications must be stored in locked compartments and that medication carts should be locked when not in use during medication administration. However, during an observation, an LPN left the Northeast Medication Cart unlocked and unattended while retrieving a computer mouse and answering a telephone call. Additionally, the LPN prepared medications for a resident and left the cart outside the resident's room unlocked and unattended. In another instance, a random observation revealed that the west medication cart was left unlocked and unattended in the hallway outside a resident's room. An LPN exited another resident's room and subsequently locked the cart. During an interview, the Director of Nursing confirmed that medication carts should not be left unlocked and unattended by nursing staff during medication administration, indicating a breach of the facility's medication storage and administration policies.
Facility Oversight Failures Lead to Safety and Behavioral Issues
Penalty
Summary
The facility administration failed to provide adequate oversight and ensure a safe environment for residents, leading to several deficiencies. The administration did not monitor and prevent dangerously elevated hot water temperatures in resident care areas. On two occasions, hot water temperatures ranging from 123 to 130 degrees Fahrenheit were recorded in eight resident rooms, posing a risk to residents, including those who were physically and cognitively impaired. The administrator was unaware of the issue, as the maintenance director did not communicate the problem effectively. Additionally, the facility failed to provide adequate supervision to prevent falls and injuries among residents. Seven residents were affected, with one resident sustaining a fracture. The facility did not conduct fall risk assessments quarterly or after each fall, as required by their policy. The director of nursing acknowledged the lack of appropriate interventions for a resident with worsening dementia, indicating a failure to implement effective fall prevention measures. The facility also failed to prevent resident-to-resident abuse and did not provide appropriate care for a resident with behavioral issues. One resident was harmed when another resident hit them with a hard plastic cup, resulting in lacerations. The resident with behavioral issues exhibited aggressive and inappropriate behaviors, including wandering, disrobing, and physical aggression towards staff and other residents. Despite being prescribed medications, the behaviors were not effectively managed, and the director of nursing admitted that adequate interventions were not in place to ensure safety.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by their policy. The policy defines a physical restraint as any device that restricts freedom of movement and cannot be easily removed by the resident. It specifies that restraints may only be used in emergency situations for brief periods and that a physician's order alone is not sufficient to justify their use. The policy also requires documentation of the anticipated length of restraint use, the frequency of release, and the type of monitoring provided. Resident #9, who was admitted with Alzheimer's Disease, Dementia, and Non-Traumatic Brain Dysfunction, was observed with a self-release seat belt that she was unable to unlatch independently. Despite the care plan indicating the use of a self-release seat belt following a fall, there was no physician's order for its use. Observations and interviews revealed that the resident was unable to release the seat belt on multiple occasions, indicating it functioned as a restraint. The Director of Nursing confirmed that the resident's inability to release the seat belt classified it as a restraint, and acknowledged that there should have been an order and documentation for its use, which was absent.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of employee-to-resident abuse involving a resident with a history of respiratory failure, depression, and dementia. The facility's policy required immediate notification of a supervisor and completion of an incident report by the charge nurse, but these steps were not followed. The incident occurred on 10/22/2023, but was not reported to the Abuse Coordinator until the following day, and no incident report or summary was provided. The Sheriff's Department concluded there was insufficient evidence to continue an investigation, and the facility could not provide documentation of a report to Adult Protective Services. Interviews with the Administrator and Director of Nursing revealed that the investigation was incomplete, with the Administrator admitting that an incident report was not completed and the Director of Nursing acknowledging the need for a narrative. The facility's failure to conduct a thorough investigation and report the incident immediately, as well as the lack of documentation and notification to Adult Protective Services, were identified as deficiencies in handling the abuse allegation.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours for two residents, as required by their policy. The policy mandates that a baseline care plan, which includes essential healthcare information and initial goals based on admission orders, must be developed within 48 hours of a resident's admission. This plan should be verified by a supervising nurse and signed by the resident or their family. However, for Resident #21, who was admitted with conditions such as Metabolic Encephalopathy and End Stage Renal Disease, the baseline care plan was initiated but left unsigned by the resident or family, thus not completed within the required timeframe. Similarly, Resident #369, admitted with diagnoses including Chronic Obstructive Pulmonary Disease and Congestive Heart Failure, also had an incomplete baseline care plan due to the lack of a signature from the resident or family. Interviews with the MDS Coordinator confirmed that the baseline care plans for both residents were not signed within 48 hours of admission, indicating a failure to adhere to the facility's policy for timely completion of baseline care plans.
Inadequate Behavioral Health Services for Resident
Penalty
Summary
The facility failed to provide adequate behavioral health services and effective behavior monitoring for a resident with significant behavioral health needs. The resident, who had a history of vascular dementia and behavioral disturbances, was admitted to the facility from a psychiatric hospital. Despite being prescribed multiple medications for agitation, anxiety, and depression, the resident exhibited a range of challenging behaviors, including wandering, entering other residents' rooms, rummaging through belongings, and displaying sexually inappropriate behaviors. These behaviors persisted from the time of admission until discharge, indicating a lack of effective interventions to manage the resident's needs. The facility's policy on behavioral health services emphasized the importance of person-centered care and monitoring for expressions of distress. However, the medical records and staff interviews revealed that the facility did not implement sufficient strategies to address the resident's behaviors. Staff documented numerous incidents where the resident was resistant to redirection and engaged in aggressive actions towards staff and other residents. The use of PRN medications like Ativan was noted, but these interventions were ineffective in controlling the resident's behaviors. Interviews with facility staff, including an LPN and a CNA, highlighted a lack of consistent communication and follow-up regarding the resident's behaviors. The Director of Nursing acknowledged that the interventions in place were inadequate to ensure the safety of both staff and residents. The facility's failure to implement effective behavioral health services and monitoring resulted in ongoing safety concerns and unmet behavioral health needs for the resident.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to ensure proper reconciliation of controlled medications, specifically Lorazepam, due to the inaction of an LPN who did not sign out the medications on the Controlled Substance Inventory Record and maintain an accurate running count. The facility's policy on narcotic control, dated August 2023, mandates that each time a controlled medication is administered, the nurse must complete the Controlled Substance Inventory Record and keep a running count of medications used and on-hand. However, during a review, it was found that the LPN did not adhere to this policy, resulting in discrepancies in the medication counts for two residents. Resident #22, diagnosed with Dementia, Carotid Artery Stenosis, Hypertension, Depression, and Generalized Anxiety Disorder, had a physician's order for Lorazepam 0.5mg three times a day. The medication card showed 4 tablets, but the inventory record indicated 5 tablets. Similarly, Resident #32, with Parkinson's Disease, Diabetes Mellitus, Chronic Kidney Disease, Major Depressive Disorder, and Generalized Anxiety Disorder, had a physician's order for Lorazepam 0.5mg twice a day. The medication card had 29 tablets, while the inventory record showed 30 tablets. The LPN acknowledged the failure to sign out the medications and maintain accurate records, which was confirmed by the DON during an interview.
Failure to Update Emergency Food Supply Menu
Penalty
Summary
The facility failed to update and revise its Three-Day Disaster Menu to accurately reflect the 3-Day Emergency Food Supply. The facility's policy on Emergency Food Supply, dated April 2022, requires maintaining a 3-to-7-day supply of nonperishable foods, with rotation and replenishment every six months. However, a review of the undated facility policy on Disaster Planning and the Three-Day Disaster Menu revealed inconsistencies. Specifically, the menu listed peanut butter and protein bars for breakfast on Days 1 and 3, but the facility's 3-Day Supply list did not include these items. During an observation and interview in the kitchen, it was confirmed that the Emergency Food Supply Menu listed peanut butter and protein bars, yet these items were absent from the Emergency Stock. The Dietary Supervisor acknowledged that food items on the menu should be present in the emergency food supply. Additionally, a Registered Dietician confirmed that any food item on the 3-day Emergency Food Supply Menu should be included in the actual supply, indicating a failure to align the menu with the available stock.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions policy during wound care for a resident, leading to a deficiency in infection prevention and control. The policy, dated May 30, 2024, mandates the use of gowns and gloves during high-contact resident care activities, such as wound care, to prevent the transmission of multidrug-resistant organisms. However, during an observation on June 26, 2024, an LPN did not wear a gown while performing wound care on a resident with an unstageable pressure injury to the coccyx. Additionally, the LPN used a strip of calcium alginate that had been dropped onto a contaminated surface, further compromising the wound care process. The resident involved was admitted with multiple diagnoses, including hemiplegia, carcinoma of the skin, dementia, and malnutrition, and was severely cognitively impaired. The resident's medical records indicated a physician's order for daily wound care, but there was no order for Enhanced Barrier Precautions. Interviews with the Infection Preventionist and the LPN confirmed that the correct PPE should have been used, and the contaminated dressing should have been disposed of, highlighting the failure to follow established infection control protocols.
Unsafe Hot Water Temperatures and Inadequate Fall Prevention
Penalty
Summary
The facility failed to maintain a safe environment by allowing dangerously elevated hot water temperatures in several resident rooms, ranging from 122.5 to 130 degrees Fahrenheit, which is above the state regulation limit of 105 to 115 degrees Fahrenheit. This issue was identified in multiple rooms, including those occupied by residents who were cognitively and/or physically impaired, placing them at risk of scalding. The Maintenance Director admitted to adjusting the water heater to a higher temperature without proper documentation or notification to the Administrator, leading to the unsafe conditions. Additionally, the facility did not provide adequate supervision and fall prevention measures for residents at risk of falls. Resident #11, who had a history of falls and severe cognitive impairment, experienced multiple falls resulting in injuries, including a closed fracture of the left distal femur. The facility's fall prevention interventions were insufficient and inconsistently implemented, as evidenced by the lack of immediate and effective measures following each fall incident. The facility's failure to address these safety hazards and implement effective interventions for fall prevention resulted in Immediate Jeopardy, a situation where the noncompliance had the potential to cause serious harm to residents. The Administrator and Maintenance Director were not adequately informed or responsive to the ongoing issues, contributing to the persistence of these deficiencies.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in actual harm. Resident #42 sustained two lacerations to the forehead when Resident #166 hit him with a hard plastic drinking cup. The facility's policies on abuse prevention and resident abuse were not effectively implemented, as Resident #166 exhibited aggressive behaviors from the time of admission, which were not adequately addressed. Resident #166 had a history of vascular dementia and was admitted to the facility with a diagnosis of dementia with agitation and behaviors. From the time of admission, Resident #166 displayed behaviors such as wandering, entering other residents' rooms, and physical aggression towards staff. Despite being prescribed antipsychotic, antidepressant, and anxiety medications, these interventions were ineffective in managing Resident #166's behaviors. The facility did not have a care plan in place for Resident #166's behaviors prior to the incident with Resident #42. Interviews with staff revealed that Resident #166 was difficult to manage and that interventions such as redirection and medication were not sufficient to ensure the safety of other residents and staff. The Director of Nursing acknowledged that adequate interventions were not put in place to keep residents and staff safe. The lack of effective measures to address Resident #166's behaviors led to the incident where Resident #42 was harmed.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure medications were properly stored and secured, as evidenced by two incidents involving medication carts being left unlocked and unattended. The facility's policy mandates that all medications must be stored in locked compartments and that medication carts should be locked when not in use during medication administration. However, during an observation, an LPN left the Northeast Medication Cart unlocked and unattended while retrieving a computer mouse and answering a telephone call. Additionally, the LPN prepared medications for a resident and left the cart outside the resident's room unlocked and unattended. In another instance, a random observation revealed that the west medication cart was left unlocked and unattended in the hallway outside a resident's room. An LPN exited another resident's room and subsequently locked the cart. During an interview, the Director of Nursing confirmed that medication carts should not be left unlocked and unattended by nursing staff during medication administration, indicating a breach of the facility's medication storage and administration policies.
Facility Oversight Failures in Safety and Behavioral Management
Penalty
Summary
The facility administration failed to provide oversight to monitor and prevent dangerously elevated hot water temperatures in resident care areas. On two separate occasions, hot water temperatures ranging from 123 to 130 degrees Fahrenheit were recorded in eight resident rooms. Despite the Maintenance Director being aware of the issue, the Administrator was not informed of the specific temperatures or the immediate jeopardy posed by the situation. This lack of communication and oversight resulted in residents, including those who were physically and cognitively impaired, being exposed to potentially harmful conditions. The administration also failed to ensure a safe environment and adequate supervision to prevent falls and injuries among residents. Seven residents were identified as having experienced falls, with one resident sustaining a fracture. The facility did not conduct fall risk assessments quarterly or after each fall, as required by their policy. The Director of Nursing (DON) acknowledged the inadequacy of interventions for a resident with worsening dementia, indicating a lack of appropriate measures to prevent accidents. Additionally, the facility failed to prevent resident-to-resident abuse and did not provide appropriate care for a resident with behavioral issues. Resident #166 exhibited aggressive and inappropriate behaviors, including hitting another resident with a hard plastic cup, resulting in harm. Despite being referred to psychiatric services and prescribed medications, the interventions were ineffective. The DON admitted that adequate measures were not in place to ensure the safety of staff and residents, highlighting a significant oversight in managing behavioral health needs.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by their policy. The policy defines a physical restraint as any device that restricts freedom of movement and cannot be easily removed by the resident. It specifies that restraints may only be used in emergency situations for brief periods and that a physician's order alone is not sufficient to warrant their use. In this case, the facility's policy was not followed, as there was no physician's order for the self-release seat belt used on the resident. The resident in question, who was severely cognitively impaired and required maximum assistance for mobility, was observed multiple times unable to release the self-release seat belt. Despite the Director of Nursing's initial belief that the resident could release the belt, it was confirmed through observation and interview that the resident could not do so without assistance. This oversight was acknowledged by the Director of Nursing, who admitted that the situation constituted a restraint and that there should have been documentation on the Treatment Administration Record to ensure the resident's ability to release the seat belt.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of employee-to-resident abuse involving a resident with a history of respiratory failure, depression, and dementia. The resident, who was moderately cognitively impaired, was involved in an incident that occurred on 10/22/2023, but the facility did not report it to the Abuse Coordinator until the following day. The facility's policy required immediate notification and investigation, but these steps were not followed. The investigation lacked an incident report or summary, and there was no documentation of a report made to Adult Protective Services. Interviews with the Administrator and Director of Nursing revealed that the investigation was incomplete. The Administrator admitted that an incident report was not completed and that the investigation was not documented as required. The Director of Nursing acknowledged that a narrative would have been beneficial. The Sheriff's Department concluded there was insufficient evidence to continue their investigation, and the facility did not provide evidence of notifying Adult Protective Services, as required by their policy.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours for two residents, as required by their policy. The policy, revised on December 5, 2022, mandates that a baseline care plan be developed and implemented within 48 hours of a resident's admission. This plan should include initial goals based on admission orders, physician orders, dietary orders, and therapy services. However, for Resident #21, who was admitted with diagnoses including Metabolic Encephalopathy, Chronic Atrial Fibrillation, Diabetes, Dialysis, and End Stage Renal Disease, the baseline care plan was initiated but left unsigned by the resident or family, thus not completed within the required timeframe. Similarly, Resident #369, admitted with diagnoses such as Chronic Obstructive Pulmonary Disease, Pneumonia, Congestive Heart Failure, Diabetes, Hypertension, and Benign Prostatic Hypertrophy, also had an incomplete baseline care plan. The plan was initiated but remained unsigned by the resident or family. Interviews with the MDS Coordinator confirmed that the baseline care plans for both residents were not signed within 48 hours of admission, indicating a failure to adhere to the facility's policy for timely completion of baseline care plans.
Inadequate Behavioral Health Services and Monitoring
Penalty
Summary
The facility failed to provide adequate behavioral health services and effective behavior monitoring for a resident with significant behavioral health needs. The resident, who had a history of vascular dementia and behavioral disturbances, was admitted to the facility from a psychiatric hospital. Despite being prescribed multiple medications for agitation and anxiety, the resident exhibited a range of disruptive and aggressive behaviors, including wandering into other residents' rooms, rummaging through belongings, and displaying sexually inappropriate behavior. These behaviors persisted throughout the resident's stay, indicating a lack of effective interventions to manage the resident's needs. The facility's policy on behavioral health services emphasized the importance of person-centered care and monitoring for expressions of distress. However, the facility did not implement sufficient measures to address the resident's behaviors. Staff documented numerous incidents of the resident's aggressive and inappropriate actions, but there was a lack of effective non-pharmacological interventions or adjustments to the care plan to mitigate these behaviors. The resident's care plan, developed after discharge, highlighted the various behavioral issues but did not reflect proactive measures taken during the resident's stay. Interviews with facility staff revealed a lack of awareness and memory regarding specific incidents involving the resident. The LPN and CNA involved in the incidents could not recall details or confirm if appropriate documentation and follow-up occurred. The Director of Nursing acknowledged the challenges in managing the resident's behaviors and admitted that the interventions in place were likely insufficient to ensure the safety of both staff and other residents. This deficiency in behavioral health services and monitoring contributed to an unsafe environment for both the resident and others in the facility.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to ensure proper reconciliation of controlled medications, as evidenced by a Licensed Practical Nurse (LPN) not signing out controlled medications on the Controlled Substance Inventory Record and failing to maintain a running count of medications on hand. The facility's policy, dated August 2023, requires that each time a controlled medication is administered, the nurse must complete the Controlled Substance Inventory Record and keep a running count of medications used and on-hand. Verification of the quantities of controlled substances must be recorded on the Controlled Dosage System - Controlled Substance - Shift Change Count Check Sheet. During a medication storage review, discrepancies were found in the controlled medication counts for two residents. One resident's Lorazepam medication card had 29 tablets, while the Controlled Substance Inventory Record showed a count of 30 tablets. The LPN admitted to administering the medication but had not signed it out on the controlled sheet. Another resident's Lorazepam medication card had 4 tablets, but the Controlled Substance Inventory Record showed a count of 5 tablets. The LPN confirmed that she should have signed the medications out in the controlled book when administering them. The Director of Nursing confirmed that nursing staff should sign the medications out on the resident's Controlled Substance Inventory Record as the medications are pulled and administered, and that the narcotic controlled counts should match the actual pill count in the medication card.
Failure to Update Emergency Food Supply
Penalty
Summary
The facility failed to update and revise its Three-Day Disaster Menu to accurately reflect the 3-Day Emergency Food Supply. The facility's policy on Emergency Food Supply, dated April 2022, requires maintaining a 3-to-7-day supply of nonperishable foods, with rotation and replenishment every six months. However, the undated policy on Disaster Planning and the Three-Day Disaster Menu included items such as peanut butter and protein bars, which were not present in the actual emergency food supply. During an observation and interview in the kitchen, it was confirmed that the Emergency Food Supply Menu listed peanut butter and protein bars, but these items were missing from the emergency stock. The Dietary Supervisor acknowledged that items listed on the menu should be available in the emergency food supply. Additionally, a Registered Dietician confirmed that any food item on the 3-day Emergency Food Supply Menu should be included in the actual supply.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions policy during wound care for a resident, leading to a deficiency in infection prevention and control. The policy, dated May 30, 2024, mandates the use of gowns and gloves during high-contact resident care activities, such as wound care, to prevent the transmission of multidrug-resistant organisms. However, during an observation on June 26, 2024, an LPN did not wear a gown while performing wound care on a resident with an unstageable pressure injury to the coccyx. Additionally, the LPN used a strip of calcium alginate that had been dropped onto a contaminated surface, further compromising the wound care process. The resident involved was admitted with multiple diagnoses, including hemiplegia, carcinoma of the skin, dementia, and malnutrition, and was severely cognitively impaired. The resident's medical records indicated a physician's order for daily wound care, but there was no order for Enhanced Barrier Precautions. Interviews with the Infection Preventionist and the LPN confirmed that the correct PPE should have been used, and the contaminated dressing should have been disposed of, highlighting the failure to follow established infection control protocols.
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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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