Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% better than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 17, 2024
Visit Reason
The inspection was conducted to investigate a complaint of physical abuse involving two residents at Beverly Park Place Health and Rehab.
Complaint Details
The complaint investigation was substantiated. Resident #14 physically struck Resident #13 in the face during a verbal argument on 12/23/2023. Witnesses and staff interviews confirmed the incident. Resident #13 denied abuse but felt safe. Resident #14's accounts were inconsistent with witness statements.
Findings
The facility failed to protect Resident #13 from physical abuse by Resident #14. The investigation confirmed that Resident #14 struck Resident #13 in the face during a verbal altercation on 12/23/2023. Multiple witness statements and staff interviews corroborated the incident. No visible injuries were observed, and both residents were separated immediately with a 1:1 sitter placed for Resident #14.
Deficiencies (1)
Failure to protect Resident #13 from physical abuse by Resident #14.
Report Facts
Residents reviewed for abuse: 7
Residents affected: 1
Date of abuse incident: Dec 23, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Weekend Supervisor | Responded to the incident, interviewed residents and assessed no injuries |
| Director of Nursing | Director of Nursing (DON) | Confirmed the physical abuse incident occurred |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 20, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report suspected abuse, neglect, or theft involving a resident.
Complaint Details
The complaint investigation involved a suspected crime where a white powdery substance was confiscated from Resident #1's room during a supervised visit with the resident's mother. The facility staff did not report the incident to the state agency or local law enforcement, believing it did not meet the criteria of a reportable event.
Findings
The facility failed to report the suspicion of a crime involving Resident #1 to the State Survey Agency, local law enforcement, adult protective services, and other officials as required by state law. An unknown white powdery substance was confiscated during a supervised visit but was not reported and was eventually discarded.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Supervisor #1 | Recalled the incident involving the confiscated white powdery substance | |
| Licensed Practical Nurse (LPN) #1 | Informed Nursing Supervisor #1 of the incident during verbal shift report | |
| Psychiatric Nurse Practitioner | Psych NP | Familiar with Resident #1 and aware of the confiscated substance |
| Administrator | ADM | Recalled the event and disposed of the confiscated substance |
| Director of Nursing | DON | Informed about the incident, questioned the resident's mother, and handled the confiscated substance |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Oct 26, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of abuse, failure to report abuse, failure to investigate abuse, and other related deficiencies at Beverly Park Place Health and Rehab.
Complaint Details
The complaint investigation involved allegations of resident-to-resident verbal abuse, failure to report the abuse timely to the State Survey Agency, and failure to investigate the abuse allegation. Resident #58 reported verbal abuse by roommate Resident #67, which staff overheard but did not report or investigate properly. The Administrator confirmed lack of notification and investigation. The CNA failed to report incidents immediately. The QAPI program failed to sustain compliance with abuse prevention and reporting.
Findings
The facility failed to protect a resident from abuse by another resident, failed to timely report and investigate allegations of abuse, failed to revise a care plan after a change in code status, failed to assist a resident with colostomy care according to preferences, and failed to properly administer medications through a PEG tube. The facility's QAPI program was also found ineffective in sustaining compliance with abuse prevention and reporting.
Deficiencies (7)
Failed to protect a resident from abuse by another resident.
Failed to timely report suspected abuse and report investigation results to proper authorities.
Failed to investigate an allegation of abuse.
Failed to revise the care plan after the resident's code status changed.
Failed to assist with colostomy care according to resident's preferences.
Failed to administer medications through a PEG enteral tube as ordered.
QAPI program failed to sustain compliance with abuse prevention and reporting.
Report Facts
Residents reviewed for abuse: 24
Residents reviewed for care plans: 32
Residents with enteral tubes reviewed: 8
Stomach residual volume withdrawn: 48
Water flush volume ordered: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding verbal abuse incidents and reporting. |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Reported hearing verbal abuse and failure to report incident. |
| Administrator | Administrator and Abuse Coordinator | Confirmed lack of notification, investigation, and reporting of abuse allegations. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed failing to properly administer medications via PEG tube. |
| Director of Nursing | Director of Nursing | Confirmed CNA failed to assist resident with colostomy care and observed medication administration errors. |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 3
Date: Sep 18, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to prevent verbal abuse of a resident, failure to complete a discharge Minimum Data Set (MDS) assessment, and failure to ensure unnecessary medications were not administered.
Complaint Details
The complaint investigation found substantiated verbal abuse of Resident #17 by CNA #1, failure to complete discharge MDS for Resident #19, and medication administration errors affecting Resident #82.
Findings
The facility failed to prevent verbal abuse of one resident (#17) by a Certified Nursing Assistant, failed to complete a discharge MDS assessment for one resident (#19), and administered unnecessary medications to one resident (#82) due to a medication order error.
Deficiencies (3)
Failed to prevent verbal abuse of 1 resident (#17) by a Certified Nursing Assistant who used foul language and was terminated.
Failed to complete a Discharge Minimum Data Set (MDS) assessment for 1 resident (#19) of 3 residents reviewed for discharge MDS assessments.
Failed to ensure unnecessary medications were not administered to 1 resident (#82) due to a medication order error where medications ordered for another resident were given.
Report Facts
Residents reviewed for abuse: 26
Residents reviewed for discharge MDS assessments: 3
Residents reviewed for unnecessary medications: 6
Medication doses administered in error: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Used foul language and verbally abused Resident #17; was terminated |
| RN #1 | Registered Nurse | Confirmed medication order error for Resident #82 and selection of wrong resident in computer |
| LPN #1 | Licensed Practical Nurse | Administered incorrect medications to Resident #82 |
| Director of Nursing | Director of Nursing (DON) | Confirmed verbal abuse incident and medication error; provided summary statements |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 12, 2018
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to refer a resident with a possible serious mental disorder for a Level II PASARR evaluation and failure to document administration of anticoagulant medication for a resident.
Complaint Details
The complaint investigation found that the facility did not refer resident #47 for a Level II PASARR evaluation despite a diagnosis of Schizoaffective Disorder. It also found failure to document administration of anticoagulant medication for resident #184, confirmed by interviews with multiple Licensed Practical Nurses.
Findings
The facility failed to refer one resident (#47) with a diagnosed Schizoaffective Disorder to the state-designated authority for a Level II PASARR evaluation. Additionally, the facility failed to document administration of Xarelto anticoagulant medication for resident #184 on multiple dates, despite confirmation from nursing staff that the medication was administered.
Deficiencies (2)
Failure to refer resident #47 with a possible serious mental disorder to the state-designated authority for a Level II PASARR evaluation.
Failure to document administration of anticoagulant medication (Xarelto) for resident #184 on multiple dates.
Report Facts
Residents reviewed for PASARR: 4
Sampled residents reviewed for anticoagulation medication: 53
Sampled residents reviewed for anticoagulation medication with deficiency: 1
Dates with missing documentation of Xarelto administration: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Responsible for completing PASARRs and confirmed failure to refer resident #47 |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Confirmed administration of Xarelto on 9/1/18 but failed to sign MAR |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Confirmed administration of Xarelto on multiple dates but failed to sign MAR |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Confirmed administration of Xarelto on 9/11/18 but failed to sign MAR |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Confirmed administration of Xarelto on 9/2/18 but failed to sign MAR |
Viewing
Loading inspection reports...
