Deficiencies (last 2 years)
Deficiencies (over 2 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Enforcement
Deficiencies: 7
Date: Feb 20, 2024
Visit Reason
The inspection and subsequent enforcement action were initiated due to violations found at Charter Senior Living at Hermitage, an assisted care living facility, including inappropriate admission of a resident and failure to maintain compliance with health, safety, and fire regulations.
Findings
The facility admitted a hospice patient inappropriately and failed to maintain a clean and sanitary kitchen, keep corridors and exit doors clear, prohibit open flame and portable space heaters, ensure operable interconnected smoke alarms, conduct required fire drills, and complete timely resident assessments.
Deficiencies (7)
Admission or retention of an inappropriately placed resident occurred with Resident #23 admitted improperly.
The facility failed to maintain a clean and sanitary kitchen, including grease buildup, grime, and dirty baseboards.
Corridors and exit doors were obstructed by equipment and multiple wheelchairs, blocking safe egress.
Open flame and portable space heaters were present in resident areas and janitorial closets, violating fire safety rules.
Electrically-operated smoke detectors with battery backup were missing or not properly connected in resident rooms.
The facility failed to provide documentation of required fire drills conducted during sleeping hours for the second quarter of 2023.
Resident #22 was not assessed within 72 hours of admission, with assessment delayed until five days after admission.
Report Facts
Civil Monetary Penalty: 4500
Civil Monetary Penalty: 500
Civil Monetary Penalty: 2000
Civil Monetary Penalty: 500
Civil Monetary Penalty: 500
Civil Monetary Penalty: 500
Civil Monetary Penalty: 500
Civil Monetary Penalty: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zachary J. Fulton | Executive Director | Signed as authorized representative of the facility. |
| Jeremy Gourley | Senior Associate General Counsel | Signed on behalf of the Health Facilities Commission Office of Legal Services. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 25, 2022
Visit Reason
An annual license survey of the assisted care living facility was conducted to determine compliance with applicable regulations.
Findings
The facility failed to maintain a clean and sanitary kitchen and did not complete required written assessments and plans of care within the mandated timeframes following resident admissions.
Deficiencies (3)
The facility failed to maintain a clean and sanitary kitchen; vents over the stove had a buildup of brown, grimy residue confirmed by the Dietary Manager.
The facility failed to complete written assessments within the required seventy-two hour period following the admissions of two residents.
The facility failed to develop plans of care for two residents within the required five day period following their admissions.
Report Facts
Civil Monetary Penalty: 1000
Civil Monetary Penalty: 1000
Civil Monetary Penalty: 1000
Number of residents with incomplete assessments: 2
Number of residents without timely plans of care: 2
Viewing
Loading inspection reports...
