Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% better than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Census: 166
Deficiencies: 6
Date: Apr 11, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident rights, staff training, medication management, food sanitation, staffing data accuracy, and infection control practices.
Findings
The facility was found deficient in multiple areas including failure to provide information on advance directives to residents, inadequate CNA in-service training hours, improper medication storage, poor food handling hygiene, inaccurate staffing data submission, and lapses in infection prevention and control practices.
Deficiencies (6)
Failed to provide information regarding residents' rights to develop an Advance Directive for 4 of 33 sampled residents.
Failed to ensure 23 of 23 CNAs employed for a full year received at least 12 hours of in-service training.
Failed to ensure medications were properly stored and secured when a nurse left medication unattended and out of sight at the bedside.
Failed to ensure food was served under sanitary conditions when staff failed to perform hand hygiene and handled food with bare hands.
Failed to submit accurate staffing data for Quarter 2, Quarter 3, and Quarter 4 of 2024, reflecting excessively low weekend staffing.
Failed to ensure infection control practices to prevent spread of infection when a nurse failed to perform hand hygiene during medication administration and a CNA did not follow Enhanced Barrier Precautions.
Report Facts
Residents affected: 4
CNAs affected: 23
Facility census: 166
PPD (Per Patient Day): 2.83
PPD (Per Patient Day): 2.96
PPD (Per Patient Day): 2.74
PPD (Per Patient Day): 2.96
PPD (Per Patient Day): 3.16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Development | Confirmed CNA in-service training hours requirement and training completion status | |
| Director of Nursing | DON | Interviewed regarding medication storage, food handling, infection control, and advance directive deficiencies |
| Certified Dietary Manager | CDM | Confirmed hand hygiene and glove use requirements during food preparation |
| Staffing Director | Interviewed regarding PBJ staffing data and weekend staffing levels | |
| Administrator | Interviewed regarding PBJ staffing data and coding of direct care hours | |
| Licensed Practical Nurse KK | LPN | Interviewed regarding Enhanced Barrier Precautions and resident care |
| Certified Nursing Assistant LL | CNA | Observed not following Enhanced Barrier Precautions while providing care |
Inspection Report
Deficiencies: 1
Date: Aug 18, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan requirements, specifically regarding the updating of a resident's care plan to reflect changes in transfer techniques following an injury.
Findings
The facility failed to update the comprehensive care plan for Resident #6 to address a change in transfer technique, despite the resident requiring extensive assistance and use of a sheet for transfers after a shoulder injury. Interviews with staff and review of records confirmed the care plan was not revised accordingly.
Deficiencies (1)
Failure to develop and implement a complete care plan that meets all the resident's needs, including timely updates to reflect changes in transfer techniques for Resident #6.
Report Facts
Residents whose care plans were reviewed: 11
Residents affected: 1
Date of incident form: May 16, 2023
Date of admission: Nov 20, 2020
Date of diagnosis addition: May 16, 2023
Date of care plan initiation: Jan 24, 2023
Date of intervention initiation: May 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Rehabilitation | Director of Rehabilitation (DOR) | Provided information on Resident #6's transfer assistance requirements and staff education |
| MDS Coordinator | MDS Coordinator | Explained how transfer requirements are documented and rolled over into care plans |
| Director of Nursing | DON | Discussed care plan update processes and expectations regarding transfer technique documentation |
| Administrator | Administrator | Described oversight responsibilities for care plan updates and departmental roles |
Inspection Report
Deficiencies: 2
Date: Oct 23, 2019
Visit Reason
The inspection was conducted to assess compliance with regulations related to food service temperatures and infection prevention and control practices, including blood glucose testing procedures.
Findings
The facility failed to maintain safe and appetizing food temperatures during meal delivery, with significant temperature losses observed. Additionally, the facility failed to follow standard precautions during routine fingerstick blood glucose testing, resulting in potential exposure to bloodborne infections and an Immediate Jeopardy citation.
Deficiencies (2)
Failed to provide food and beverages at a palatable and appetizing temperature for one tray delivery cart containing 22 resident meal trays.
Failed to follow standard precautions during routine fingerstick blood glucose testing, resulting in potential exposure to bloodborne infections for 3 of 32 diabetic residents.
Report Facts
Residents affected: 22
Meal service delivery time: 43
Food temperatures before delivery: 186
Food temperatures before delivery: 193
Food temperatures before delivery: 177
Food temperatures before delivery: 199
Food temperatures before delivery: 158
Food temperatures before delivery: 192
Food temperatures before delivery: 190
Food temperatures before delivery: 41.6
Food temperatures before delivery: 16.5
Food temperatures after delivery: 119.8
Food temperatures after delivery: 115
Food temperatures after delivery: 116.8
Food temperatures after delivery: 121.6
Food temperatures after delivery: 119
Food temperatures after delivery: 115.5
Food temperatures after delivery: 114.8
Food temperatures after delivery: 55
Food temperatures after delivery: 29.5
Diabetic residents affected: 3
Total diabetic residents: 32
Fingerstick blood glucose testing times: 7.5
Glucometer audits duration: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Performed fingerstick blood glucose testing without proper glucometer disinfection |
| DON | Director of Nursing | Confirmed glucometer disinfection procedures and oversight |
| Unit Manager | Removed and disinfected glucometers, educated nurses, and conducted competency checks | |
| Administrator | Conducted QAPI meeting to address root cause and facility plan |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 11, 2018
Visit Reason
The inspection was conducted following complaints and allegations of physical abuse involving two residents at the facility, as well as concerns about food sanitation and infection control.
Complaint Details
The complaint investigation substantiated physical abuse against Resident #316 by CNA #1 who threw a plate lid hitting the resident's face, causing a laceration and nasal fracture. CNA #1 was arrested on site. Resident #26 was physically abused by Dietary Aide #3 who punched him after he made racial slurs; the Dietary Aide was terminated. Both incidents were confirmed by video evidence and interviews.
Findings
The facility failed to protect two residents from physical abuse by staff members, resulting in actual harm to one resident. Additionally, the facility failed to ensure sanitary food service practices and proper infection control related to PICC line dressing changes.
Deficiencies (4)
Failed to protect Resident #316 from physical abuse when a CNA threw a plate lid hitting the resident's face causing injury.
Failed to protect Resident #26 from physical abuse when a Dietary Aide punched the resident in the face.
Failed to ensure food was served under sanitary conditions when a male dietary employee was observed working without a beard net.
Failed to change a soiled PICC line dressing as ordered for Resident #1.
Report Facts
Length of laceration: 4
Medication doses: 3
Date of PICC dressing: Jun 20, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Assistant | Named in physical abuse incident involving Resident #316; arrested on site |
| Dietary Aide #3 | Dietary Aide | Named in physical abuse incident involving Resident #26; terminated from employment |
| LPN #2 | Licensed Practical Nurse | Witnessed and reported the abuse incident involving Resident #316 |
| LPN #5 | Licensed Practical Nurse | Night supervisor who responded to the abuse incident involving Resident #316 |
| Administrator | Facility Administrator | Notified and responded to abuse incident involving Resident #316 |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse incidents and confirmed findings |
| Dietary Manager | Dietary Manager | Confirmed failure to wear beard net in food service observation |
| Unit Manager | Unit Manager | Removed Dietary Aide #3 from situation and confirmed abuse; confirmed PICC dressing issue |
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