Deficiencies (over last year)
Deficiencies (over last year)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
32% better than Tennessee average
Tennessee average: 4.4 deficiencies/year
Deficiencies per year
4
3
2
1
0
Inspection Report
Enforcement
Deficiencies: 3
Date: Apr 26, 2023
Visit Reason
An annual licensure survey and complaint investigation were conducted following a Life Safety Code Survey that found the facility not in substantial compliance with Tennessee Rules and Regulations.
Complaint Details
The complaint investigation was conducted as part of the annual licensure survey. The facility was found not in substantial compliance with applicable Tennessee Rules and Regulations.
Findings
The facility failed to provide documentation of required fire drills for multiple shifts and periods, and failed to ensure resident safety, resulting in multiple falls with injury and lack of proper fall risk assessments and care plan updates.
Deficiencies (3)
The facility failed to provide documentation of required 1st and 2nd shift fire drills for all of 2022 and the first quarter of 2023.
The facility failed to provide documentation of required 3rd shift sleeping hours fire drills for all of 2022 and the first quarter of 2023.
The facility failed to ensure that Resident #3 and Resident #6 were provided safety while in the facility, resulting in multiple falls with injury and lack of fall risk assessments or care plan updates after falls.
Report Facts
Civil Monetary Penalty: 3000
Civil Monetary Penalty: 500
Civil Monetary Penalty: 3000
Calendar days: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bradley Hamilton | Executive Director | Named as Authorized Representative of the facility in the Consent Order. |
| Vishan J. Ramcharan | Associate General Counsel | Signed the Consent Order on behalf of the Health Facilities Commission. |
| Director of Nursing | Confirmed to surveyors that the facility did not complete fall risk assessments or update care plans for Resident #3 and Resident #6 after falls. |
Loading inspection reports...
