Deficiencies (last 2 years)
Deficiencies (over 2 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Enforcement
Deficiencies: 0
Date: May 28, 2025
Visit Reason
The document concerns an Order of Compliance related to the Assisted Care Living Facility license following a Contingent Change of Ownership Order dated January 22, 2025, and the early termination of probation.
Findings
The Commission found that the conditions of the January 22, 2025 Contingent Change of Ownership Order were met, leading to the lifting of probation on the facility's license and restoration to active status. The Order included payment of civil monetary penalties totaling $16,000.
Report Facts
Civil monetary penalties: 16000
Probation duration: 6
Inspection Report
Enforcement
Deficiencies: 8
Date: Sep 3, 2024
Visit Reason
The inspection was conducted as a Life Safety survey on September 3, 2024, followed by a licensure and complaint survey on October 4, 2024, at The Pointe at Kirby Gate Assisted Care Living Facility.
Complaint Details
The complaint investigation was conducted on October 4, 2024, confirming medication administration failures and safety issues. Specific substantiation status is not stated.
Findings
The facility failed to prohibit portable space heaters, conduct required quarterly fire drills, administer medications properly, maintain resident safety, conduct fall risk assessments, follow food safety policies, maintain a clean kitchen, and keep accurate resident records and plans of care. Multiple violations were documented, resulting in civil monetary penalties.
Deficiencies (8)
Tenn. Comp. R. and Regs. 0720-26-.10 (2)(h) [Life Safety]: The facility failed to prohibit portable space heaters as required.
Tenn. Comp. R. and Regs. 0720-26-.10 (2)(h) [Life Safety]: The facility failed to conduct quarterly fire drills for each shift for the 2nd and 4th quarters of 2024.
Tenn. Comp. R. and Regs. 0720-26-.07(5)(b) [Services Provided]: The facility failed to ensure all drugs and biologicals were administered by licensed staff according to the resident's plan of care.
The facility failed to keep residents safe, resulting in unlocked windows in the secure unit and multiple falls and injuries between June 2023 and October 2024.
The facility failed to conduct fall risk assessments, perform root-cause analysis on falls, and update residents' plans of care to address falls and injuries.
The facility failed to follow food safety policies, resulting in expired, unlabeled, and deteriorated food, and lacked temperature logs for June and July 2024.
The facility failed to maintain a clean and sanitary kitchen from September 16 through 18, 2024, with observed unsanitary conditions and improper food handling.
The facility failed to maintain medical records, including documentation of resident discharges, transfers, and updates to plans of care as residents' conditions changed.
Report Facts
Civil Monetary Penalty: 16000
Business days: 10
Probation period: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nastasya Shannon | Director of Senior Living | Signed as authorized representative of the facility. |
| Jessica Thomas | Administrator | Named in certificate of service for document delivery. |
| Jeremy J. Gourley | Senior Associate General Counsel | Signed legal document on behalf of Health Facilities Commission. |
| Anthony Tarantino | President | Named as Assignee in Assignment and Relinquishment of License. |
| Cory Bennett | Authorized Signatory | Named as Assignor in Assignment and Relinquishment of License. |
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