Deficiencies (last 2 years)
Deficiencies (over 2 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Tennessee average
Tennessee average: 4.4 deficiencies/year
Deficiencies per year
8
6
4
2
0
Inspection Report
Enforcement
Deficiencies: 7
Date: Jan 8, 2024
Visit Reason
The document is a Consent Order issued by the Tennessee Board for Licensing Health Care Facilities regarding violations found at Belvedere Commons of Franklin, an assisted care living facility. The order addresses disciplinary actions and penalties related to regulatory violations.
Findings
The facility failed to provide appropriate care and oversight, including failure to protect residents from injury and abuse, failure to maintain a clean and sanitary kitchen, and failure to update care plans for residents with changing needs. Multiple violations of Tennessee regulations were documented, resulting in civil monetary penalties.
Deficiencies (7)
Oversight of medical services was inadequate, leading to untreated injury and lack of awareness of home health agency involvement on January 8, 2024.
Protective care was not provided following a suspected sexual assault involving residents, with failure to notify law enforcement or document interventions.
Safety measures were insufficient, including short staffing during resident altercations and failure to respond promptly to unresponsive residents.
Daily awareness of residents' whereabouts was lacking, exemplified by failure to locate a resident who eloped and inadequate supervision.
The kitchen was found unsanitary on multiple dates with buildup of debris, improper dishwasher function, and staff failing to follow cleaning protocols.
The facility failed to review and revise care plans for residents with wandering, sexual, aggressive behaviors, medications, and dementia-related needs.
Interventions were not implemented for residents' wandering, injury, sexual assaults, elopement risk, aggressive behaviors, or inappropriate sexual behaviors.
Report Facts
Civil Monetary Penalty: 500
Civil Monetary Penalty: 500
Civil Monetary Penalty: 2000
Civil Monetary Penalty: 500
Civil Monetary Penalty: 3000
Civil Monetary Penalty: 3000
Civil Monetary Penalty Total: 9500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Margie Ann Watkins | Director of Community Relations | Authorized representative of the facility who signed the Consent Order. |
Inspection Report
Enforcement
Deficiencies: 2
Date: Oct 11, 2022
Visit Reason
This document is a Consent Order issued by the Tennessee Board for Licensing Health Care Facilities regarding violations found at Belvedere Commons of Franklin Assisted Care Living Facility. The order addresses disciplinary action following deficiencies cited during a survey.
Findings
The facility was found to have violated regulations related to resident safety and care plan development. Specifically, a resident was injured due to a wheelchair malfunction during transport, and care plans for several residents were not reviewed or revised to reflect changes in their needs.
Deficiencies (2)
Tenn. Comp. R. and Reg. 0720-26-.07(7)(a)(2): The facility failed to provide safety when in the assisted care living facility, resulting in a resident injury during transport due to a wheelchair front wheel lock not being engaged.
Tenn. Comp. R. and Reg. 0720-26-.12(5)(a): The facility failed to develop and review care plans for residents admitted to the facility, as care plans for several residents were not updated or revised to reflect changes in their needs.
Report Facts
Civil Monetary Penalty: 1000
Civil Monetary Penalty: 1000
Total Penalties: 2000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Margie Ann Watkins | Executive Director | Confirmed care plans for residents had not been updated or revised |
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