Wexford House
Inspection history, citations, penalties and survey trends for this long-term care facility in Kingsport, Tennessee.
- Location
- 2421 John B Dennis Highway, Kingsport, Tennessee 37660
- CMS Provider Number
- 445207
- Inspections on file
- 24
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Wexford House during CMS and state inspections, most recent first.
A facility failed to report an allegation of abuse involving a resident with cognitive capacity and complex medical needs, after staff reported that a CNA had taken unauthorized photos of the resident and allegedly sent them to the ombudsman. The resident stated she did not consent to the photos, and the DON documented the resident's concerns. Despite these reports, the Administrator did not notify the State Survey Agency as required by policy.
Staff responsible for testing dishwasher sanitizer levels lacked the necessary competency to follow manufacturer guidelines, as evidenced by the consistent documentation of a chlorine rinse result not available on the test strip guide and inability to explain or properly interpret test results.
Surveyors identified extensive sanitation failures in the kitchen, including dirty equipment, improper food storage, overflowing trash, and infrequent cleaning of the ice machine and deep fryer. Staff interviews confirmed the lack of a cleaning schedule and improper handwashing practices, with these deficiencies potentially affecting nearly all residents.
Facility staff did not consistently monitor or document resident refrigerator temperatures as required by policy, with several refrigerators found above the recommended temperature and some logs incomplete. Expired food items were also found in resident refrigerators, and staff failed to discard them as per facility guidelines. These deficiencies were confirmed by the DON during observations and interviews.
A resident with severe cognitive impairment and multiple medical conditions was found to be living in a room with missing wallpaper, peeling paint, and additional wallpaper damage, which the Maintenance Director was unaware of and acknowledged did not meet homelike standards.
A resident with a history of daily smokeless tobacco use, who was cognitively intact and had multiple medical diagnoses, did not have their tobacco use addressed in their care plan. Despite facility policy and staff acknowledgment that tobacco use should be included, the care plan was not updated to reflect this need, as confirmed by medical record review, observations, and staff interviews.
The facility did not follow its policy requiring on-site destruction of unused narcotics witnessed by appropriate staff. Instead, narcotics from discharged or deceased residents were collected and processed off-site, and key staff were unaware that this practice did not align with facility policy.
Staff did not provide required hand hygiene assistance to three residents with cognitive and physical impairments before meal service, despite facility policy mandating this practice. Observations and interviews confirmed that CNAs delivered meal trays and allowed residents to eat without offering hand hygiene, and the DON acknowledged the lapse in infection control procedures.
The facility did not maintain kitchen cooking equipment in a sanitary condition, potentially affecting 82 out of 86 residents. Observations revealed a large sheet pan with crusty, greenish-brown food debris, a hot food holding cabinet with dried, black, greasy food debris, and a plate warmer with dried, brownish-yellow residue. The undated policies on sanitizing pots, pans, and equipment were not followed.
The facility failed to maintain residents' dignity by serving milk products in disposable cartons without offering glasses and by having a CNA feed a resident while standing over them. Interviews revealed a lack of awareness regarding regulations for non-disposable dishware, and the practice of serving milk in cartons was routine without resident requests.
The facility failed to accurately complete MDS assessments for two residents. One resident's admission MDS did not list Quadriplegia as an active diagnosis despite being dependent on staff for various activities. Another resident's quarterly MDS did not list Hypothyroidism as an active diagnosis despite receiving daily medication for the condition.
The facility failed to include a cognitively intact resident in the care planning process, despite the resident requiring substantial assistance with daily activities. The resident did not receive invitations to quarterly care plan meetings, nor a copy of the latest care plan, which was acknowledged as an oversight by the Social Services Director and confirmed by the Director of Nursing.
The facility failed to ensure expired supplies were not available for resident use in one of the three medication carts observed. An LPN found expired cotton swabs, a specimen collection swab kit, and blood draw vials in the 300 long hall medication cart. The DON confirmed these items should not have been on the cart.
The facility failed to properly contain garbage and refuse in two dumpsters, leaving them exposed to air, elements, and potential pests. The Food Service Manager confirmed that the dumpsters should have been tightly closed, as per facility policies.
Failure to Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency as required by its own policy. The policy mandates that the Abuse Coordinator, who is the Administrator, is responsible for reporting all allegations or suspicions of abuse, including mental abuse facilitated through technology, to the state survey agency. In this case, several staff members reported that a CNA had taken photos of a resident's back or wounds and sent them to the ombudsman. The resident involved, who was cognitively intact and required assistance with activities of daily living, stated that she did not give permission for any photos to be taken. The Director of Nursing documented that the resident reported photos were taken without her knowledge. The Administrator interviewed the CNA, who denied taking or sending any photos and denied using her phone in the facility. No staff reported actually seeing the photos on the CNA's or any other employee's phone. Despite the allegations and statements from staff and the resident, the Administrator did not report the incident to the State Survey Agency, stating that although it is normally done, it was not done in this instance. The ombudsman confirmed not receiving any photos or having any related discussions. The failure to report the allegation of abuse, as required by facility policy and regulation, constitutes the deficiency identified in the report.
Incompetent Staff Testing of Dishwasher Sanitizer Levels
Penalty
Summary
The facility failed to employ staff with the appropriate competencies to ensure manufacturer guidelines were followed for testing chemical sanitation in the dishwasher. Review of the Dishmachine Temperature Record for the specified month showed that chlorine rinse readings of 50 were consistently documented for all meals, despite the fact that the test strips and their guide did not include a 50 ppm reading as an option. During observation, the Certified Dietary Manager (CDM) demonstrated difficulty reading the test strips and was unsure of the correct reading, asking the surveyor for guidance and instructing a Dietary Aide to test the chemical results in a manner inconsistent with standard procedure. When questioned about how the recorded results of 50 ppm were obtained, neither the CDM nor the Dietary Aide could provide an explanation.
Widespread Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain kitchen equipment and food storage, preparation, and serving areas in a clean and sanitary condition, as required by professional standards and facility policy. Observations revealed multiple sanitation issues, including a black substance on the ice machine in contact with ice, lack of paper towels at the hand washing station, and staff using a sink designated for pots and pans to wash their hands. Numerous pieces of kitchen equipment, such as can openers, mixers, microwaves, ovens, deep fryers, and warming racks, were found with dried food debris, grease, or other contaminants. Food items were improperly stored, with undated containers, wet-nested pans, and open or unlabeled items in coolers and freezers. Trash cans in food preparation areas were uncovered, overflowing, and in contact with clean storage containers. Additionally, maintenance records showed the ice machine was only cleaned twice a year, and the deep fryer was cleaned about every six months. Interviews with dietary staff and the Registered Dietician confirmed the absence of a cleaning schedule and acknowledged that the kitchen was not maintained in a sanitary condition. The Maintenance Director verified the infrequent cleaning of the ice machine. These deficiencies had the potential to affect 80 of 81 residents, as the unsanitary conditions could compromise the safety and quality of food served to residents.
Failure to Monitor Resident Refrigerator Temperatures and Remove Expired Foods
Penalty
Summary
The facility failed to adhere to its policy regarding the monitoring and maintenance of resident personal refrigerators, as well as the management of food items stored within them. Observations revealed that temperature logs for several residents' refrigerators were incomplete, with missing daily recordings on specific dates. Additionally, recorded temperatures frequently exceeded the facility's policy requirement of maintaining refrigerator temperatures below 41°F, with some logs showing temperatures as high as 44°F and 60°F. In one instance, a thermometer inside a resident's refrigerator displayed a temperature of 73°F. These lapses were confirmed during interviews and observations. Further deficiencies were noted in the handling of expired food items. Expired yogurt was found in the refrigerators of two residents, with expiration dates that had already passed. The facility's policy required that foods with use-by dates be discarded accordingly, but this was not consistently followed. The residents involved had various medical conditions, including dementia, hemiplegia, diabetes, chronic kidney disease, and other significant diagnoses. The DON confirmed that the facility did not ensure daily monitoring and documentation of refrigerator temperatures, did not maintain required temperature levels, and did not consistently discard expired foods as per policy.
Failure to Maintain Homelike Resident Room Environment
Penalty
Summary
The facility failed to provide a homelike environment for one resident who was admitted with diagnoses including hemiplegia, dysphagia, and intracranial injury, and who was noted to be severely impaired in cognitive skills for daily decision making. Observations in the resident's room revealed a large piece of wallpaper missing from the wall beside the bed, a large area of missing paint near the head of the bed, and wallpaper peeling away from the baseboard by the window. During an interview, the Maintenance Director stated he was not aware of these issues and confirmed that the room was not consistent with a homelike environment and required repairs.
Failure to Address Tobacco Use in Resident Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan addressing tobacco use for a resident who was cognitively intact and used smokeless (chewing) tobacco daily. Despite the facility's policy requiring comprehensive assessments and care plans that include all resident needs, preferences, and treatments, the resident's ongoing use of smokeless tobacco was not incorporated into their care plan. Medical record reviews confirmed the resident's tobacco use, and observations over several days showed the resident keeping and using smokeless tobacco in their room. Interviews with staff, including an LPN and the DON, confirmed that the resident's tobacco use was known and that such information should be included in the care plan. However, the care plan had not been updated to reflect this aspect of the resident's care, despite clear evidence from assessments, observations, and staff interviews that the resident regularly used smokeless tobacco.
Failure to Follow Policy for On-Site Destruction of Narcotics
Penalty
Summary
The facility failed to follow its own policy regarding the destruction of unused narcotics. According to the facility's undated policy, the destruction of drugs must be conducted on the premises and witnessed by the consultant pharmacist along with either an agent of the State Board of Pharmacy, the facility administrator, or the director of nursing services. However, review of the Narcotic Destruction Logs revealed that while the logs listed residents' names, medications, amounts of narcotics remaining, nurses' initials, and reasons for destruction, they did not document the actual destruction of the narcotics as required by policy. Interviews with the Assistant Director of Nurses (ADON), the Administrator, and the Consultant Pharmacist confirmed that narcotics belonging to residents who had expired or been discharged were not destroyed on the facility premises. Instead, a collection process was used, and the drugs were processed off-site. Both the ADON and the Administrator were unaware that the facility's practice did not align with its written policy, and the Consultant Pharmacist was also not aware of the discrepancy between the policy and the actual process for narcotic destruction.
Failure to Provide Hand Hygiene Assistance During Meal Service
Penalty
Summary
During meal service, staff failed to follow proper infection control practices related to hand hygiene for three residents who required assistance with activities of daily living (ADLs), including personal hygiene. Facility policy required staff to perform hand hygiene before and after eating, but observations revealed that staff did not offer or provide hand hygiene assistance to these residents prior to their lunch meals. Specifically, staff brought meal trays, opened silverware, and allowed residents to begin eating without ensuring hand hygiene was performed. The residents involved had significant medical conditions and cognitive impairments, including pelvis fracture, chronic kidney disease, anemia, diabetes, anxiety, weakness, hemiplegia, chronic respiratory failure, and heart failure. Their care plans and Minimum Data Set (MDS) assessments indicated they were dependent on staff for personal hygiene. Interviews with staff and the Director of Nursing confirmed that hand hygiene assistance was not provided as required by facility policy during the observed meal service.
Sanitation Issues with Kitchen Cooking Equipment
Penalty
Summary
The facility failed to ensure kitchen cooking equipment was maintained in a sanitary condition, potentially affecting 82 out of 86 residents. The undated policies on sanitizing pots and pans and equipment were not followed, as evidenced by observations on 3/18/2024. A large sheet pan had crusty, greenish-brown food debris, the hot food holding cabinet had dried, black, greasy food debris, and the plate warmer had dried, brownish-yellow residue.
Failure to Maintain Resident Dignity in Meal Service and Feeding Assistance
Penalty
Summary
The facility failed to ensure staff maintained residents' dignity by serving milk products in disposable cartons without offering glasses to nine residents across three of five hallways observed for meal tray distribution. The facility's policy on patient/resident rights and dining experience emphasized the importance of dignified and courteous treatment, yet this was not upheld. Observations and interviews revealed that residents were routinely served milk and nutritional shakes in disposable cartons without being offered glasses, and there was no evidence in the medical records that residents had requested this practice. Several residents, including those with cognitive impairments and those who were cognitively intact, confirmed they had not requested to receive their milk in disposable cartons and were not offered glasses, although they expressed varying levels of concern about the practice. Additionally, the facility failed to maintain a resident's dignity during feeding. One resident, who was totally dependent on staff for eating due to severe cognitive impairment and physical limitations, was observed being fed by a CNA who stood over the resident rather than sitting at eye level. This practice was contrary to the facility's expectations for feeding assistance, which required staff to be seated and at eye level with the resident. The CNA admitted to standing over the resident because it was more convenient for her, indicating a disregard for the resident's dignity and the facility's policies. Interviews with the facility's administration and dietary staff revealed a lack of awareness regarding regulations related to providing non-disposable cutlery and dishware, including cups and glasses. The Administrator, Director of Nursing, and dietary staff all confirmed that milk and nutritional shakes were routinely served in disposable cartons and that glasses were only provided upon resident request. This practice was a long-standing one, and there was no evidence that the facility had considered the impact on residents' dignity or made efforts to align with regulatory requirements for a dignified dining experience.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for two residents. Resident #78, who was admitted with diagnoses including Amyotrophic Lateral Sclerosis (ALS) and Quadriplegia, had an admission MDS that did not list Quadriplegia as an active diagnosis. This was despite the resident being dependent on staff for personal hygiene, dressing, transfers, and bed mobility, and the comprehensive care plan noting the risk for limitations in range of motion related to Quadriplegia. The Director of Nursing confirmed that the admission MDS assessment for Resident #78 was not accurate and did not reflect the resident's active diagnosis of Quadriplegia upon admission. Similarly, Resident #56, who was admitted with diagnoses including Adult Failure to Thrive, Hypothyroidism, Alzheimer's Dementia, and Major Depressive Disorder, had a quarterly MDS assessment that did not list Hypothyroidism as an active diagnosis. This was despite the resident having a physician's order for Levothyroxine and receiving the medication daily, as noted in the Medication Administration Record (MAR). The MDS Coordinator confirmed that Resident #56's quarterly MDS assessment was coded incorrectly and did not include the active diagnosis of Hypothyroidism.
Failure to Include Cognitively Intact Resident in Care Planning Process
Penalty
Summary
The facility failed to include Resident #31 in the care planning process, despite the resident being cognitively intact and requiring substantial assistance with daily activities. The facility's policy mandates that residents and their families be informed and invited to care plan meetings, with documentation of these attempts. However, Resident #31 did not receive invitations to the quarterly care plan meetings, nor did she receive a copy of the latest care plan. The Social Services Director (SSD) admitted that the resident was not invited to the meetings and had no documentation to show that the resident did not want to participate. Resident #31 was admitted with diagnoses including Pneumonia, Arthritis, and Diabetes Mellitus. Despite being cognitively intact, the resident was not included in the care planning process. The SSD acknowledged the oversight and confirmed that the resident had never received an invitation to or attended the quarterly care plan meetings. The Director of Nursing (DON) also confirmed that it was her expectation for cognitively intact residents to be involved in their care plan meetings, indicating a lapse in following the facility's policy.
Expired Supplies Found on Medication Cart
Penalty
Summary
The facility failed to ensure expired supplies were not available for resident use in one of the three medication carts observed. During an observation and interview with an LPN, it was found that the 300 long hall medication cart contained expired supplies, including a package of two cotton swabs, a specimen collection swab kit, three vacuum blood draw vials, and one blood draw vial. The LPN acknowledged the presence of the expired supplies and stated that the protocol was to remove such items and notify the supervisor. The Director of Nursing confirmed that the expired supplies should not have been on the medication cart.
Improper Containment of Garbage and Refuse
Penalty
Summary
The facility failed to ensure garbage and refuse were properly contained in two dumpsters. During an observation, it was noted that the hard, plastic roof covering dumpster #1 was open, and dumpster #2's sliding door on the right side was also open. This left the contents of both dumpsters exposed to air, elements, and potential pests. The Food Service Manager confirmed that the dumpsters should have been tightly closed to prevent exposure to elements and potential rodents, as per the facility's policies on garbage and trash cans and maintaining a home-like environment.
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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