Deficiencies (last 4 years)
Deficiencies (over 4 years)
1.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
66% better than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 23, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of resident-to-resident sexual abuse involving two residents at the facility.
Findings
The facility failed to prevent resident-to-resident sexual abuse involving two cognitively impaired residents. The incident was investigated and determined likely consensual but willful. The facility implemented multiple interventions including 1:1 supervision, resident relocation, psychiatric evaluations, staff re-education, and ongoing monitoring. No physical or psychosocial harm was found and corrective actions were validated on site.
Complaint Details
The complaint involved an incident where Resident #1 was observed with his hand inside Resident #2's brief. Both residents were cognitively impaired and had no recall of the incident. The investigation concluded the act was likely consensual but willful. The facility reported the incident to authorities within 2 hours and implemented multiple corrective actions.
Severity Breakdown
Scope and Severity of D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect residents from all types of abuse including sexual abuse. | Scope and Severity of D |
Report Facts
Severity level: 1
Medication dosage increase: 25
Medication dosage increase: 75
Staff re-education count: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Nurse on duty at time of incident who interviewed CNAs and reported details of the event | |
| Certified Nurse Aides (CNAs) B and C | Staff who found the residents during the incident and provided observations | |
| Director of Nursing (DON) | Reported facility investigation conclusions and participated in quality assurance | |
| Mental Health Provider | Performed telehealth and in-person psychiatric evaluations and follow-up assessments | |
| Facility Social Worker | Documented arrangements for resident transfer |
Inspection Report
Routine
Deficiencies: 3
Feb 14, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with accurate resident assessments, coordination with pre-admission screening and resident review programs, and proper referral for services as needed.
Findings
The facility failed to accurately complete Minimum Data Set (MDS) assessments for 3 residents, failed to refer one resident for a Level II PASRR evaluation after diagnosis of a serious mental disorder, and did not document or order care for an indwelling urinary catheter for a resident inaccurately reported to have one.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to accurately complete Minimum Data Set (MDS) assessments for 3 residents (#132, #32, and #73). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document or order care for an indwelling urinary catheter for Resident #32, despite MDS indicating otherwise. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to refer Resident #94 for a Level II Pre-admission Screening and Resident Review (PASRR) evaluation after diagnosis of PTSD. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for MDS assessments: 27
Residents affected: 3
Residents reviewed for PASRR: 7
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Confirmed inaccuracies in MDS assessments for Residents #132, #32, and #73 | |
| Licensed Practical Nurse (LPN) #1 | Stated Resident #32 never had an indwelling urinary catheter | |
| Certified Nursing Assistant (CNA) #1 | Stated Resident #32 never had an indwelling urinary catheter | |
| Director of Nursing (DON) | Confirmed MDS indicating Resident #32 had an indwelling urinary catheter was inaccurate | |
| Licensed Practical Nurse (LPN) #2 | Confirmed Resident #73 was NPO | |
| Certified Nursing Assistant (CNA) #2 | Confirmed Resident #73 was NPO | |
| Director of Clinical Services | Confirmed failure to refer Resident #94 for Level II PASRR evaluation |
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 29, 2021
Visit Reason
Annual inspection survey completed for Senator Ben Atchley State Veterans' Home to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection. The level of harm and residents affected are unknown.
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 24, 2019
Visit Reason
The inspection was conducted based on complaints regarding failure to document Certified Nurse Aide (CNA) participation in the Care Plan process for multiple residents and failure to complete an accurate falls risk assessment for one resident.
Findings
The facility failed to provide documentation of CNA participation in the Care Plan process for 20 of 37 residents reviewed, and failed to complete an accurate falls risk assessment for one resident who sustained a fall with injury. Interviews with staff confirmed these deficiencies.
Complaint Details
The complaint investigation found substantiated deficiencies related to lack of CNA participation documentation in care planning for 20 residents and inaccurate falls risk assessment for 1 resident who fell and was injured.
Severity Breakdown
Level of Harm - Potential for minimal harm: 1
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide documentation of Certified Nurse Aide (CNA) participation in the Care Plan process for 20 residents. | Level of Harm - Potential for minimal harm |
| Failed to complete an accurate falls risk assessment for 1 resident, resulting in an inaccurate assessment after a fall with injury. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for CNA participation: 37
Residents with missing CNA documentation: 20
Residents reviewed for falls risk assessment: 6
Residents with falls risk assessment deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Responsible for falls investigation and falls risk assessment; failed to include fall in assessment |
| Director of Nursing | Director of Nursing | Confirmed failure to provide documentation of CNA participation and inaccurate falls risk assessment |
| MDS Coordinator Registered Nurse #1 | Registered Nurse | Interviewed regarding CNA participation documentation failure |
| MDS Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding CNA participation documentation failure |
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