Inspection Reports for
Belmont Village Memphis
6605 N Quail Hollow Rd, Memphis, TN 38016, Memphis, TN, 38120
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Enforcement
Deficiencies: 2
Date: Dec 11, 2024
Visit Reason
The visit was a Life Safety survey conducted by Commission surveyors on or about December 11, 2024, to assess compliance with fire and life safety code rules at Belmont Village Assisted Care Living Facility.
Findings
The facility failed to produce documentation of required quarterly fire drills for each work shift and fire drills during sleeping hours for the 2nd and 3rd quarters of 2024. The Administrator admitted that the fire drills were not conducted as required.
Deficiencies (2)
Tenn. Comp. R. and Regs. 0720-26-.10 (3)(a) [Life Safety] requires fire drills for each ACLF work shift quarterly. The facility failed to conduct fire drills for the 2nd shift in the 2nd and 3rd quarters of 2024.
Tenn. Comp. R. and Regs. 0720-26-.10 (3)(b) [Life Safety] requires one fire drill per quarter during sleeping hours. The facility failed to conduct fire drills during sleeping hours for the 2nd and 3rd quarters of 2024.
Report Facts
Civil Monetary Penalty: 1000
Civil Monetary Penalty: 1000
Total Civil Monetary Penalty: 2000
License Expiration Date: License expiration date is May 11, 2025.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Crump | Executive Director | Named as Respondent's Administrator who admitted fire drills were not conducted. |
Inspection Report
Enforcement
Deficiencies: 1
Date: Oct 11, 2023
Visit Reason
The document is a Consent Order related to a disciplinary enforcement action against Ascension Living Alexian Village Tennessee Skilled Nursing Facility following a review and investigation by the Tennessee Health Facilities Commission.
Findings
The facility failed to immediately notify a resident's physician after an accident resulting in injury and requiring physician intervention. The resident was entrapped between their mattress and bed grab bar, and the physician was not notified until four hours after the event.
Deficiencies (1)
The facility failed to immediately notify the resident's physician when an accident occurred resulting in injury and requiring physician intervention. Notification was delayed by four hours after the resident was found entrapped between their mattress and the grab bar attached to their bed.
Report Facts
Civil Monetary Penalty: 3000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Rief | Executive Director | Authorized representative who signed the Consent Order. |
| Jeremy Gourley | Senior Associate General Counsel | Legal counsel for the Health Facilities Commission involved in the Consent Order. |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Apr 15, 2019
Visit Reason
On or about April 15, 2019, surveyors conducted an annual licensure survey at Belmont Village to assess compliance with state laws and regulations.
Findings
Surveyors observed serious violations related to dietary services, food storage, sanitation, and staff management, resulting in endangerment to residents' health, safety, and welfare. A revisit survey was conducted on June 7, 2019, to determine if deficiencies had been corrected.
Deficiencies (11)
An open and uncovered bowl of ice cream was found in the ice cream box, and the Chef Manager mishandled it, failing to provide daily management and accountability for dietary services.
The walk-in freezer had icicles on pipes and ice on food boxes, and the Chef Manager directed the surveyor to maintenance without addressing the issue.
The Chef Manager failed to ensure hot foods were maintained at 140 degrees Fahrenheit or above and lacked a written policy for food holding temperatures and storage.
The Chef Manager improperly sanitized the food thermometer between uses and was not wearing gloves during food temperature checks.
Food items were improperly stored in refrigerators, freezers, and dry storage areas.
Residents expressed dissatisfaction with overcooked food and the Chef Manager's refusal to meet and discuss concerns.
The kitchen ceiling tiles were blackened and vents greasy and dusty, confirmed unacceptable by the Building Engineer.
The facility's diet manual lacked instructions on special diets, and staff had no direction on serving special diets to residents with diabetes.
The facility failed to implement its plan of correction for proper food storage in kitchen, refrigerators, and freezers.
Dietary employees failed to add dish sanitizer to the dishwasher and did not sanitize utensils and dishes after use.
Three dietary employees were observed without hairnets, and staff failed to change gloves or wash hands after handling supplies.
Report Facts
Civil monetary penalties: 1500
Temperature readings: 125
Temperature readings: 112
Temperature readings: 114
Temperature threshold: 140
Meals per day: 3
Hours between meals: 14
Food supply storage duration: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chef Manager | Named in multiple findings related to food handling, temperature checks, sanitation, and staff management. | |
| Building Engineer | Reported issues with freezer fan and kitchen ceiling and vents. |
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