Inspection Reports for
Camden Healthcare and Rehabilitation Center
197 Hospital Drive, Camden, TN, 38320
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 1, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide adaptive eating devices as ordered by the physician for Resident #15.
Complaint Details
Complaint investigation related to failure to provide adaptive eating devices as ordered. The deficiency was substantiated based on policy review, medical record review, observations, and interviews.
Findings
The facility failed to ensure Resident #15 received the ordered adaptive devices, specifically a two-handled cup and divider plate, resulting in the resident spilling drinks and stopping eating. Observations and interviews confirmed that staff did not provide the required adaptive equipment despite having sufficient supplies.
Deficiencies (1)
Failure to provide special eating equipment and utensils as ordered by the physician for Resident #15, leading to food and drink spillage.
Report Facts
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant H | Certified Nursing Assistant | Confirmed Resident #15 was supposed to have a two-handled cup. |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed staff should follow physician's orders and provide adaptive equipment at mealtime. |
| Dietary Manager | Dietary Manager | Confirmed the facility had enough two-handled cups to provide for residents. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: May 1, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, safety, medication management, and facility operations.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, failure to ensure a safe environment to prevent accidents, inadequate monitoring and documentation of psychotropic medication use, failure to implement gradual dose reductions for psychotropic drugs, and failure to provide ordered adaptive eating equipment to residents.
Deficiencies (5)
Failed to ensure MDS assessments were accurately coded for a resident's fall with major injury.
Failed to ensure a safe environment to prevent potential accidents including inadequate supervision during smoking breaks and incomplete follow-up after falls.
Failed to provide appropriate behavioral monitoring for psychotropic medications for a resident with vascular dementia.
Failed to ensure PRN psychotropic medications were limited to 14 days duration and lacked physician rationale for continued use beyond 14 days for hospice residents.
Failed to provide a resident with adaptive eating equipment as ordered by the physician.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 1
PRN Lorazepam administrations: 18
PRN Lorazepam administrations: 22
PRN Lorazepam administrations: 21
PRN Lorazepam order duration: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed about X-ray results and medication orders |
| Director of Nursing | Director of Nursing (DON) | Interviewed about vital signs after falls and smoking assessments |
| Medical Director | Medical Doctor (MD) | Interviewed about vital signs, medication monitoring, and behaviors |
| Social Service Director | Social Service Director (SSD) | Interviewed about behaviors and psychotropic medication use |
| Pharmacist | Pharmacist | Interviewed about gradual dose reduction and PRN medication regulations |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) H | Confirmed resident should have two handled cup |
| Dietary Manager | Dietary Manager (DM) | Confirmed availability of two handled cups |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 17, 2024
Visit Reason
The inspection was conducted due to allegations of abuse, neglect, and failure to report and investigate incidents involving inappropriate sexual behaviors and other forms of abuse by Resident #38 towards multiple residents.
Complaint Details
The complaint investigation revealed multiple incidents of abuse by Resident #38 including inappropriate touching, sexual comments, and unwanted physical contact with residents #6, #13, #20, #24, #25, and others. The facility failed to report these incidents timely to appropriate agencies and failed to conduct thorough investigations. Resident #6 reported feeling fearful and uncomfortable due to these incidents, which triggered past trauma. Other residents also reported distress and embarrassment. The facility was cited for Immediate Jeopardy due to the risk of serious injury or harm.
Findings
The facility failed to protect residents from abuse, including inappropriate sexual behaviors by Resident #38 towards several residents, and failed to timely report and thoroughly investigate these allegations. Immediate Jeopardy was cited due to the risk of serious harm to residents. Multiple residents reported feeling unsafe and uncomfortable due to Resident #38's behaviors. The facility also failed to report allegations of verbal abuse and sexual abuse to appropriate authorities and failed to conduct adequate investigations.
Deficiencies (3)
Failure to protect residents from all types of abuse including sexual abuse by Resident #38 towards multiple residents.
Failure to timely report allegations of abuse to State Survey Agency, Adult Protective Services, and Ombudsman for multiple residents.
Failure to thoroughly investigate allegations of abuse involving Resident #38 and other residents.
Report Facts
Residents reviewed for abuse: 16
Residents affected by abuse incidents: 7
BIMS score: 8
BIMS score: 15
BIMS score: 12
BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN J | Licensed Practical Nurse | Reported Resident #38's inappropriate touching of Resident #6 and failure to report |
| CNA A | Certified Nursing Assistant | Reported Resident #20's agitation and inappropriate comment by Resident #38 |
| Social Service Director | Involved in reporting and investigation failures related to Resident #38's behaviors | |
| Activities Director | Held meeting with female residents about Resident #38's behaviors and failed to report to Administrator | |
| Administrator | Abuse Coordinator | Responsible for reporting abuse allegations; failed to ensure timely reporting and investigation |
| Director of Nursing | DON | Failed to be informed of abuse incidents and failed to assist in investigations |
| Psychiatric Nurse Practitioner | Psych NP | Provided psychiatric evaluation and medication recommendations for Resident #38 |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Apr 17, 2024
Visit Reason
The inspection was conducted due to complaints and allegations of abuse, neglect, and safety concerns involving multiple residents, including inappropriate sexual behaviors, verbal abuse, and unsafe smoking practices.
Complaint Details
The complaint investigation involved allegations of abuse including sexual abuse by Resident #38 towards multiple residents, verbal abuse to Resident #5, and safety concerns including falls and smoking practices. The facility was cited for Immediate Jeopardy due to failure to protect residents from abuse, failure to timely report abuse, and failure to thoroughly investigate allegations.
Findings
The facility failed to maintain residents' dignity, failed to protect residents from abuse including sexual abuse, failed to timely report allegations of abuse to appropriate agencies, failed to thoroughly investigate abuse allegations, and failed to ensure a safe environment including safe smoking practices and proper sharps disposal. Immediate Jeopardy was cited related to abuse and reporting failures.
Deficiencies (6)
Failed to maintain or enhance resident's dignity when staff required residents to say please and thank you before granting requests and referred to residents as hens.
Failed to ensure residents' right to be free from abuse including sexual abuse by Resident #38 towards multiple residents, resulting in Immediate Jeopardy.
Failed to timely report allegations of abuse to State Survey Agency and other agencies for multiple residents, resulting in Immediate Jeopardy.
Failed to thoroughly investigate all alleged violations of abuse for multiple residents, resulting in Immediate Jeopardy.
Failed to ensure a safe and secure environment when residents were observed lighting cigarettes from existing lit cigarettes, failed to obtain witness statements for falls, and failed to properly discard sharps/razors.
Failed to provide effective administrative oversight to ensure policies and procedures were followed to protect residents from abuse and ensure thorough investigations and timely reporting.
Report Facts
Residents affected by dignity deficiency: 8
Residents affected by abuse deficiency: 6
Residents affected by smoking deficiency: 4
Residents affected by fall investigations: 3
Residents with unsecured razors observed: 2
Fall dates for Resident #24: 5
Fall dates for Resident #53: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN J | Licensed Practical Nurse | Reported Resident #38 grabbed Resident #6's chair and arm but did not report initially |
| CNA A | Certified Nursing Assistant | Reported Resident #20 agitated after Resident #38 made comment about chest; documented on dashboard |
| Social Service Director | Managed behavior program, reported facility behaviors to Administrator and DON, involved in resident interviews | |
| Administrator | Facility Administrator and Abuse Coordinator | Responsible for reporting abuse, failed to ensure timely reporting and investigations |
| Director of Nursing | Director of Nursing | Responsible for nursing program, failed to ensure investigations and reporting of abuse |
| Activities Director | Held meeting with female residents about Resident #38, failed to report concerns to Administrator | |
| Psychiatric Nurse Practitioner | Provided psychiatric care and medication for Resident #38 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 3, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to report and investigate accidents, specifically a fall involving Resident #93, and concerns about respiratory care for Residents #11 and #22.
Complaint Details
The complaint investigation revealed that Resident #93's fall on 8/18/2021 was not reported by staff, and the facility was unable to provide documentation of any education provided to staff related to reporting falls or incidents. Interviews with staff confirmed lack of notification and reporting.
Findings
The facility failed to ensure that accidents were reported and investigated for Resident #93 who sustained a left hip fracture after a fall. Additionally, the facility failed to ensure oxygen supplies were changed and dated for Residents #11 and #22 receiving respiratory services.
Deficiencies (2)
Failure to ensure accidents were reported and investigated for Resident #93 after a fall resulting in a left hip fracture.
Failure to ensure oxygen supplies were changed and dated for Residents #11 and #22 receiving respiratory services.
Report Facts
Date of fall: Aug 18, 2021
Oxygen tubing date: Oct 14, 2021
Empty humidifier bottle date: Oct 19, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Provided verbal statement confirming Resident #93 found on floor | |
| CNA #1 | Certified Nursing Assistant | Assisted Resident #93 and provided verbal statement about fall incident |
| CNA #2 | Certified Nursing Assistant | Assisted Resident #93 and provided verbal statement about fall incident |
| LPN #1 | Licensed Practical Nurse | Assessed Resident #93 and confirmed lack of notification about fall |
| Director of Nursing | Director of Nursing | Confirmed fall was not reported and staff education was insufficient |
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