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
Surveyors conducted an annual licensure survey at Belmont Village to assess compliance with state laws and regulations related to health, safety, and welfare of residents.
Findings
Surveyors observed serious violations including improper food handling, failure to maintain proper food temperatures, inadequate sanitation practices, and failure to implement the plan of correction. The facility also failed to ensure dietary services met regulatory requirements and maintain a clean and sanitary kitchen.
Deficiencies (11)
An open and uncovered bowl of ice cream was found in the ice cream box, and the Chef Manager behaved unprofessionally by throwing the bowl and shouting at staff. The Chef Manager failed 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 checked food temperatures improperly, including sticking the thermometer into multiple foods without sanitizing and wiping it with the same paper towel, failing to maintain hot foods at 140°F or above.
The facility failed to properly store food items in refrigerators, freezers, and dry storage areas.
Residents expressed dissatisfaction with overcooked food and the Chef Manager's refusal to meet with them to discuss concerns.
The Building Engineer reported a non-working freezer fan and leaking pipes; kitchen ceiling tiles were blackened and vents greasy and dusty, which were deemed unacceptable.
The facility's diet manual lacked instructions for special diets, and staff confirmed no direction was provided on serving special diets to residents with diabetes.
The facility failed to implement the plan of correction to properly store food items in the kitchen, refrigerators, and freezers.
Dietary employees failed to add dish sanitizer to the dishwasher and did not sanitize utensils and dishes after each use.
Three dietary employees were observed without hairnets, and the facility failed to ensure all dietary staff wore hairnets in the kitchen.
Staff went to the storeroom for supplies, returned to the kitchen to prepare meat, and failed to change gloves or wash their hands.
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 duration: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chef Manager | Named in multiple findings related to food handling, temperature monitoring, sanitation, and management failures. | |
| Building Engineer | Reported freezer fan malfunction and kitchen maintenance issues. |
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