Based on the TN Department of Health Guidelines for Sex Offenders, Registered Sex Offender Registry review, policy review, personnel file review, and interview, the facility failed to protect 24 of 24 residents from 1 of 3 (Licensed Practical Nurse (LPN) A), whose criminal background check revealed a criminal conviction and placement on the Tennessee Bureau of Investigation (TBI) Registered Sex Offender Registry. The findings include: 1. Review of the Tennessee Department of Health Guidelines for Sex Offenders revealed, .individuals with certain sex offender convictions are permanently prohibited from working in long-term care facilities due to background check requirements. The Tennessee Department of Health (TDH) prohibits employment for anyone with a disqualifying event which includes specific sex-related offenses . 2.Review of the TBI Sex Offender Registry revealed LPN A was placed on the registry on 3/28/2023 for aggravated statutory rape, exploitation of a minor by electronic means, and solicitation of a minor. 3. Review of the facility's undated policy titled, POLICY - ABUSE, NEGLECT AND EXPLOITATION, revealed, .Policy .Each resident has the right to be free from abuse .Residents must not be subject to abuse by anyone including but not limited to.facility staff The facility must .Not employ or otherwise engage individuals who: a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property by a court of law.Facility administration should report to the . nursing board, any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service. 4. Review of the personnel record for LPN A revealed a hire date of 8/31/2023. The criminal background check dated 8/30/2023 revealed a felony conviction of aggravated statutory rape, solicitation of a minor, aggravated rape, and soliciting sexual exploitation of a minor. During an interview on 9/18/2025 at 3:30 PM, the Administrator was asked if he was aware LPN A was on the Tennessee Sex Offender Registry. The Administrator stated, .yes, I was . The Administrator was asked if (LPN A) was currently employed at the facility as a direct care nurse. The Administrator stated, .yes . The Administrator was asked was he aware that sex offenders should not be employed at a care facility. The Administrator stated .yes.

Based on policy review, TN Department of Health Guideline for sex offender review, personnel file review, Registered Sex offender review, and interview, the facility failed to administer in a manner to maintain the highest practicable physical, mental, and psychosocial well-being for 24 of 24 residents by employing Licensed Practical Nuse (LPN) A, a Registered Sex Offender. The findings include: 1.Review of the facility's undated policy titled, . ABUSE, NEGLECT AND EXPLOITATION, revealed, .Policy .Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation.Residents must not be subject to abuse by anyone including but not limited to; facility staff .The facility must .Not employ or otherwise engage individuals who: a. Have been found guilty of abuse, neglect, exploitation.Facility administration should report to . nursing board, any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service. Review of the Tennessee Department of Health Guidelines for Sex Offenders revealed, .individuals with certain sex offender convictions are permanently prohibited from working in long-term care facilities due to background check requirements. The Tennesse Department of Health (TDH) prohibits employment for anyone with a disqualifying event which includes specific sex-related offenses . 2. Review of the personnel file for LPN A revealed .Date of Hire 8/31/2023.Background Screening Report.County Criminal Records Search.Search Date 8-30-2023.File Date 2023-3-23.FELONY.OFFENSE.AGGRAVATED STATUTORY RAPE.SOLICIATION OF A MINOR - AGGRAVATED RAPE.SOLICITING SEXUAL EXPLOITATION OF A MINOR. 3.Review of the Tennessee Sex Offender Registry revealed .STATUS ACTIVE.DATE OF OFFENSE.6/01/2022.AGGRAVATED STATUATORY RAPE.12/21/2022 EXPLOITATION OF A MINOR BY ELECTRONIC MEANS.0601/2022 SOLICIATATION OF A MINOR: MISDEMEANOR, CLASS D OR E FELONY.CRIMINAL HISTORY.2023-3-28.CHARGE SOLICITING SEXUAL EXPLOITATION OF A MINOR.CONVICTED.2023-3-28 SOLICIATION OF A MINOR - AGGRAVATED STATUATORY RAPE.CONVICTED. During an interview on 9/18/25 at 3:30 PM, the Administrator stated he was aware LPN A was on the Tennessee Sex Offender Registry and acknowledged LPN A was currently employed at the facility. The Administrator stated he was aware that sex offenders should not be employed at a long term care facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure residents were free from significant medication errors when 2 of 7 (Licensed Practical Nurse (LPN) A and LPN B) nurses failed to follow physician orders for 1 of 5 (Resident #5) residents reviewed for unnecessary medications. The findings include: 1. Review of the facility policy titled, Administration of Drugs, dated 1/21/2022, revealed .Medications shall be administered as prescribed by the attending physician .Medications must be administered in accordance with the written orders of the attending physician . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Paroxysmal Atrial Fibrillation, Major Depressive Disorder, Hypertension, and Cerebrovascular Disease. Review of the Physician Order dated 11/20/2023, revealed .Metoprolol Tartrate Oral Tablet .Give 12.5 mg [milligram] by mouth two times a day .HOLD IF HEART RATE IS LESS THAN 60 bpm [beats per minute] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was unable to complete a Brief Interview for Mental Status (BIMS). Review of the Care Plan dated 5/21/2025, revealed . [named Resident #5] has hypertension (HTN) .Give anti hypertensive medications as ordered. Monitor for side effects .Metoprolol Tartrate Oral Tablet (Metoprolol Tartrate) Give 12.5 mg [milligrams] by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD IF HEART RATE IS LESS THAN 60 bpm [beats per minute] . Review of the Medication Administration Record (MAR) dated 5/2025, revealed Metoprolol Tartrate was given as follows: On 5/11/2025 at 7:00 AM with heart rate of 59 by LPN A. On 5/19/2025 at 7:00 AM with heart rate of 58 by LPN A. On 5/27/2025 at 7:00 AM with heart rate of 52 by LPN A. On 5/28/2025 at 7:00 AM with heart rate of 56 by LPN A. On 5/31/2025 at 7:00 AM with heart rate of 58 by LPN B. 3. During an interview on 6/10/2025 at 2:08 PM, the Director of Nursing (DON) confirmed staff should follow physician orders. During an interview on 6/10/2025 at 3:22 PM, LPN A confirmed that she gave Metoprolol Tartrate at 7:00 AM when Resident #5 had a heart rate of less than 60 bpm on 5/11/2025, 5/19/2025, 5/27/2025, and 5/28/2025.

Based on facility policy and interview, the facility failed to follow its policy and provide education and vaccination for COVID-19 to 3 of 5 (Licensed Practical Nurse (LPN) C, Laundry Supervisor, and Certified Nursing Assistant (CNA) D staff members interviewed. The findings include: 1. Review of the undated facility policy titled, COVID-19 Vaccination, revealed .It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine .It is the policy of this facility, in collaboration with the medical director, to have an immunization program against COVID-19 disease in accordance with national standards of practice .The facility will educate and offer the COVID-19 vaccine to .staff and maintain documentation of such . 2. During interview on 6/10/2025 at 3:43 PM, LPN C confirmed that she had not been offered education or vaccination for COVID-19. During interview on 6/10/2025 at 3:53 PM, the Laundry Supervisor confirmed that she had not been offered education or vaccination for COVID-19. During interview on 6/10/2025 at 3:57 PM, CNA D confirmed that she had not been offered education or vaccination for COVID-19. During interview on 6/10/2025 at 4:36 PM, the Director of Nursing (DON) confirmed that they do not offer education and vaccination for COVID-19 to employees.

Based on review of the facility ' s Licensure Staffing Requirements, daily staffing schedules, staff time punches, and interview, the facility failed to ensure a Registered Nurse (RN) was on duty at least 8 consecutive hours a day, 7 days a week, for 111 of 160 days reviewed. The findings include: 1. Review of the facility ' s daily working schedule for 1/2025, revealed no RN was on duty for 8 consecutive hours on 1/1/2025-1/3/2025, 1/6/2025-1/11/2025, 1/13/2025-1/17/2025, and 1/19/2025-1/30/2025. Review of the facility ' s time punches dated 1/2025, revealed RN E worked 7 hours and 45 minutes on 1/4/2025, 1/12/2025 and 1/18/2025, resulting in no RN coverage for 8 consecutive hours on those days. 2. Review of the facility ' s daily working schedule for 2/2025, revealed no RN was on duty for 8 consecutive hours on 2/3/2025-2/5/2025, 2/7/2025, 2/10/2025-2/14/2025, 2/17/2025-2/19/2025, 2/21/2025-2/23/2025, and 2/25/2025-2/28/2025. Review of the facility ' s time punches dated 2/2025, revealed RN F worked 7 hours and 45 minutes on 2/8/2025 and 2/9/2025, and RN E worked 7 hours and 45 minutes on 2/15/2025 and 2/16/2025, resulting in no RN coverage for 8 consecutive hours on those days. 3. Review of the facility ' s daily working schedule dated 3/2025, revealed no RN was on duty for 8 consecutive hours on 3/3/2025, 3/5/2025, 3/7/2025, 3/10/2025-3/14/2025, 3/17/2025, 3/19/2025-3/21/2025, 3/24/2025-3/28/2025, and 3/31/2025. Review of the facility ' s time punches dated 3/2025, revealed RN E worked 7 hours and 45 minutes on 3/1/2025, 3/2/2025, 3/16/2025, and 3/29/2025. RN F worked 7 hours and 45 minutes on 3/8/2025, resulting in no RN coverage for 8 consecutive hours on those days. 4. Review of the facility ' s daily working schedule dated 4/2025, revealed no RN was on duty for 8 consecutive hours on 4/2/2025-4/4/2025, 4/7/2025-4/11/2025, 4/14/2025, 4/15/2025, 4/17/2025, 4/18/2025, 4/21/2025-4/25/2025, and 4/28/2025-4/30/2025. 5. Review of the facility ' s daily working schedule dated 5/2025, revealed no RN was on duty for 8 consecutive hours on 5/1/2025, 5/2/2025, 5/5/2025-5/9/2025, 5/12/2025-5/16/2025, 5/19/2025-5/23/2023, and 5/26/2025-5/30/2025. 6. Review of the facility ' s daily working schedule dated 6/2025, revealed no RN was on duty for 8 consecutive hours on 6/1/2025-6/6/2025, and 6/9/2025. During an interview on 6/10/2025 at 2:13 PM, the Assistant Director of Nursing (ADON) confirmed she makes the schedules for Certified Nursing Assistants, Licensed Practical Nurses, and Registered Nurses. The ADON confirmed that the Director of Nursing (DON) is scheduled for 4 hours each day Monday through Friday. During an interview on 6/10/2025 at 3:00PM, the Administrator confirmed the DON, and the facility owner are RNs, and they can cover if needed. The Administrator confirmed that the facility does not have a staffing waiver.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Infection Control Policy and Procedure Manual, and interview the facility failed to provide a qualified Infection Control Preventionist who was responsible to monitor and maintain the facility ' s Infection Prevention and Control Program. This could have affected the 26 residents residing in the facility. The findings include: Review of the facility ' s Infection Control Policy and Procedure Manual INFECTION CONTROL PROGRAM revealed, .The goals of the Infection Control Program are to .Decrease the risk of infection to patients and personnel .Monitor for occurrence of infection and implement appropriate control measures .Identify and correct problems relating to infection control practices .Insure compliance with state and federal regulations relating to infection control .The administrator is ultimately responsible for the Infection Control Program .Responsibility is delegated to the Infection Control Practitioner (ICP) to carry out the daily functions of the Infection Control Program .Patient Infections Cases are monitored by the ICP .The ICP completes the .listing of infections and monthly report form and reports .Monthly to the Administrator .Quarterly to the Infection Control Committee . Review of the Infection Prevention Control Officer Training Certificate dated [DATE] revealed the facility ' s Infection Preventionist Certificate had expired three years from the date the certificate was issued. During an interview on [DATE] at 4:45 PM, the Administrator confirmed the Infection Preventionist certification had expired and stated, .we didn't know till you showed us . During an interview on [DATE] at 5:10 PM, the Director of Nursing (DON) confirmed that her Infection Preventionist Training had expired and stated, I had no idea it had expired .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, it was determined the facility failed to report an injury of unknown origin and an allegation of sexual abuse to State Agencies within 2 hours for 2 of 3 (Resident #1 and #2) sampled residents reviewed for alleged abuse. The findings include: 1. Review of the facility's undated policy titled Policy - Abuse, Neglect and Exploitation revealed .Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .GUIDELINES: 1. The Abuse coordinator in the facility is the Director of Nursing, Administrator, or Social Worker. Report allegations or suspected abuse, neglect or exploitation immediately to: Administrator, Other Officials in accordance with State Law, State Survey and Certification agency through established procedures .The Facility Must .In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the advents that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other official (including the State Survey Agency and adult protected services where state law provides for jurisdiction in long-term care facilities) in accordance with State law . 2. Review of the Emergency Department Progress Note dated [DATE], revealed .nurse from [NAME] Home Nursing Home, called with report on patient [Resident #1]. Reports that patient was found in bed approximately 20 minutes ago with deformity of left shoulder. Reports that a CNA [Certified Nursing Assistant] went to her room to get her up for a bath and found her in bed with obvious deformity of left shoulder. Denies that any staff knows what happened . Review of the facility's Incident/Accident Report dated [DATE], revealed .Resident [Resident #1] was being showered and CNA made nurse aware of (L) [left] shoulder looking different that (R) [right] .apparent dislocation to (L) shoulder . Review of the medical record revealed Resident #1 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's Disease, Vascular Dementia, Dislocation of Left Shoulder Joint, Osteoarthritis, Cerebrovascular Disease, and Vitamin D Deficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored 3 on the Staff Assessment for Mental Status which indicated severely impaired cognition. Resident #1 was dependent upon staff for all Activities of Daily Living (ADLs). Observations on [DATE] at 10:40 AM in the lobby revealed Resident #1 was reclined in a geri-chair. The resident's eyes were closed, and she did not respond when name called. A sling used for a mechanical lift was underneath the resident. 3. Review of the medical record revealed Resident #2 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Metabolic Encephalopathy, Vascular Dementia, Cerebrovascular Disease, Hemiplegia and Hemiparesis of Left Non-Dominant Side, Adjustment Disorder, and Impulse Disorder. The resident expired on [DATE]. Review of the Speech Language Pathologist typed statement dated [DATE], revealed .I was getting ready to leave the room and [Named Resident #2] says, you have to get me out of here I'm being sexually assaulted .I then reported this to [Named ADON] . Review of the Significant Change MDS assessment dated [DATE], revealed Resident #2 scored 9 on the Brief Interview of Mental Status which indicated moderately impaired cognition. Resident #2 was dependent upon staff for all ADLs. Review of the Advanced Practice Registered Nurse's summary dated [DATE], revealed .When I asked him [Resident #2] about his anxiety, depression, or concerns, he stated that he had been assaulted .I spoke with [Named ADON] . Review of the Social Worker's typed statement dated [DATE], revealed .I was informed by [Named ADON] that resident [Resident #2] had reported being sexually assaulted .I approached resident who was resting in bed .I asked him if anything else had taken place and his response was 'he tried putting his fingers inside me' .I immediately reported this to [Named ADON] and the Administrator . 4. During an interview with the Administrator on [DATE] at 3:04 PM, when asked what was the timeframe for reporting an injury of unknown origin or an allegation of abuse, the Administrator stated, I thought it was 5 days, or is it 24 hours? I missed that one. I didn't know to report injury of unknown origin .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess residents for activities of daily living for 2 of 13 sampled residents (Resident #3 and #7) reviewed for Minimum Data Set (MDS) assessments. The findings include: Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses Diabetes, Vascular Dementia with Behavioral Disturbance, Psychotic Disorder, and Age-Related Physical Debility. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #3 required supervision for bed mobility and was independent for eating. Review of the quarterly MDS dated [DATE], revealed Resident #3 required limited assistance for bed mobility and required supervision for eating. During an interview on 11/9/2021 at 10:10 AM, MDS Coordinator #1 confirmed the MDS dated [DATE] for Resident #3 was inaccurate for bed mobility and eating, and should have been assessed as supervision for bed mobility and independent for eating. Medical record review, revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Heart Disease, Cerebrovascular Disease, Delusional Disorders, and Osteoarthritis. Review of the quarterly MDS dated [DATE], revealed Resident #7 required extensive assistance for eating. Review of the annual MDS dated [DATE], revealed Resident #7 was totally dependent on staff for eating. During an interview on 11/9/2021 at 10:10 AM, MDS Coordinator #1 confirmed the MDS dated [DATE] for Resident #7 was inaccurate and should have been assessed as totally dependent on staff for eating.

Based on policy review, observation, and interview, the facility failed to ensure medications were labeled and stored appropriately when undated, opened, unlabeled, and unsecured medications were observed in 2 of 23 resident bathrooms (Resident #24 and Resident #238's bathroom) which could have potentially affected 2 identified wanderers (Resident #14 and Resident #20) in the facility. The findings include: Review of the facility's policy titled, POLICY- MEDICATION STORAGE ROOM, dated 9/21/2021, revealed .treatment supplies will be kept in .original packages .All containers will be labeled with expiration date and date opened . Observations in Resident #24's and Resident #238's bathroom on 11/7/2021 at 9:02 AM, 10:50 AM, 12:55 PM, and 2:30 PM, revealed 2 opened plastic medication cups with an unidentified white substance sitting on the bathroom shelf that was undated, opened, unlabeled, and unsecured. The facility identified 2 wanderers (Resident #14 and Resident #20) who could have potentially been affected by unsecured medications left unattended in resident bathrooms. During an interview on 11/7/2021 at 2:35 PM, Licensed Practical Nurse (LPN) #1 was asked what was in the 2 medication cups in Resident #24's and Resident #238's bathroom. LPN #1 stated, .I think this is Baza cream [a treatment for irritated skin] .not sure what kind of medication it is .no it shouldn't be left here . During an interview on 11/9/2021 at 11:26 AM, the Director of Nursing (DON) confirmed that the undated, opened, unlabeled, and unsecured medications should not have been left unattended in a resident bathroom.

Based on policy review, observation, and interview, the facility failed to ensure 3 of 7 staff (Certified Nurse Assistant (CNA) #1 and #2, and Registered Nurse (RN) #1) served food under sanitary conditions when staff touched food with their bare hands and failed to perform hand hygiene for 4 of 25 sampled residents (Resident #14, #18, #19, and #26) observed during dining. The findings include: Review of the facility's undated policy titled, Hand Washing Reminders, revealed .Remember to wash Hands When .After coming in contact with resident's belongings/surfaces in room . Review of the facility's undated policy titled, Meal Time Reminders, revealed .Do not touch food with bare hands. Use forks, knives, spoons, and if need wear gloves . Observation in the Dining Room on 11/7/2021 at 11:35 AM, revealed RN #1 handled Resident #19's crackers with her bare hands. Observation in the resident's room on 11/7/2021 at 11:45 AM, revealed CNA #1 moved the bedside table near Resident #14 who was sitting on the side of the bed. CNA #1 sat down in the chair at the bedside. Without performing hand hygiene, CNA #1 removed Resident #14's sandwich from a plastic bag with her bare hands and placed the sandwich in Resident #14's hands. Resident #14 lost grip of the sandwich and CNA #1 touched the sandwich with her bare hands. CNA #1 then touched the bedside table and chair to reposition them. CNA #1 touched the feeding end of the spoon with her bare hands, without performing hand hygiene, and began feeding Resident #14. Observation in the resident's room on 11/8/2021 at 4:45 PM, revealed CNA #2 handled Resident 18's sandwich with her bare hands. Observation in the resident's room on 11/8/2021 at 4:48 PM, revealed CNA #2 handled Resident 26's sandwich with her bare hands. During an interview on 11/9/2021 at 10:53 AM, the Director of Nursing (DON) confirmed that staff should not handle food bare-handed, and staff should perform hand hygiene after touching residents or objects.