Deficiencies (over last year)
Deficiencies (over last year)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Enforcement
Deficiencies: 6
Date: Jun 13, 2023
Visit Reason
The inspection and investigation were conducted due to violations found at Fountains of Franklin Assisted Care Living Facility, leading to disciplinary action and enforcement by the Tennessee Board for Licensing Health Care Facilities.
Findings
The facility was found to have multiple violations including medication administration by an unlicensed staff member, failure to maintain a clean and sanitary kitchen, failure to maintain proper dietary services and documentation, and failure to review and revise resident care plans semi-annually. Civil monetary penalties were assessed for these deficiencies.
Deficiencies (6)
Tenn. Comp. R. and Reg. 0720-26-.07 (5)(b): Medication was administered by a staff member with an expired nursing license who was not authorized to perform medication administration.
Tenn. Comp. R. and Reg. 0720-26-.07 (7)(c)(1): The facility failed to have organized dietary services directed and staffed by qualified personnel, and the dietary manager modified menus without dietitian review or approval.
Tenn. Comp. R. and Reg. 0720-26-.07 (7)(c)(3): The facility did not maintain a current therapeutic diet manual approved by a dietitian and available to staff.
Tenn. Comp. R. and Reg. 0720-26-.07 (7)(c)(4)(i): The facility failed to ensure hot foods were maintained at 140°F or above and failed to maintain a sanitary kitchen with buildup of grime and residue on kitchen equipment.
Tenn. Comp. R. and Reg. 0720-26-.07 (7)(c)(5): The facility failed to maintain a clean and sanitary kitchen as evidenced by dirty stove, ovens, vent hood, toaster, fryer, and pots.
Tenn. Comp. R. and Reg. 0720-26-.12 (5)(a): The facility failed to review or revise care plans for five residents at least semi-annually to reflect changes in needs or conditions.
Report Facts
Civil Monetary Penalty: 1000
Civil Monetary Penalty: 3000
Civil Monetary Penalty: 1000
Number of residents with care plan deficiencies: 5
Number of large pots with buildup: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robin Michelle Crowell | Executive Director | Admitted suspension of staff member with expired license and was the authorized representative signing the consent order. |
| Staff Member #1 | Medication Aide | Observed administering medication without a valid nursing license and admitted to having keys to the medication cart. |
| Dietary Manager | Admitted to modifying menus without dietitian review and failure to maintain cleaning logs for kitchen. | |
| Director of Nursing | DON | Admitted that care plans for residents #1, #2, #3, #4, and #5 were not reviewed or revised semi-annually. |
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