Deficiencies (last 3 years)
Deficiencies (over 3 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% better than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Enforcement
Deficiencies: 2
Date: Feb 17, 2023
Visit Reason
A complaint survey of the assisted care living facility was conducted on or about February 17, 2023, following concerns about failure to provide protective care and update a resident's plan of care.
Complaint Details
The complaint investigation was substantiated, finding the facility failed to provide protective care and update the care plan for Resident #1 who exhibited exit-seeking behavior and eloped from the facility.
Findings
The facility failed to provide protective care for one resident and did not update the resident's care plan after documented exit-seeking behavior and an elopement incident. A civil monetary penalty was assessed for these deficiencies.
Deficiencies (2)
Tenn. Comp. R. and Reg. 0720-26-.07(7)(a)1 requires each ACLF to provide protective care. The facility failed to provide protective care for one resident.
Tenn. Comp. R. and Reg. 0720-26-.12(5)(a) requires development and timely revision of a plan of care. The facility failed to update the plan of care for one resident after exit-seeking behavior was documented.
Report Facts
Civil Monetary Penalty: 4000
License Number: 185
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shane A. Jones | Executive Director | Authorized representative who signed the consent order. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 1, 2019
Visit Reason
The Department of Health conducted a complaint survey at Chandler House from April 1, 2019 through April 5, 2019, following concerns about resident safety and care.
Complaint Details
The complaint investigation was substantiated based on findings that Resident #1 eloped from the facility due to inadequate safety measures and monitoring.
Findings
Resident #1 was found to have eloped from the facility and was admitted to the hospital with hypothermia. The facility failed to complete a written Wandering/Elopement Risk tool and did not consistently conduct required 30-minute checks to prevent elopement. A Plan of Correction was submitted and the facility was found in compliance upon re-visit on May 29, 2019.
Deficiencies (1)
Rule 1200-08-25-.07(7)(a)(2) requires safety for residents. The facility failed to complete a Wandering/Elopement Risk tool for Resident #1 and did not consistently conduct 30-minute checks, resulting in Resident #1 eloping and being hospitalized with hypothermia.
Report Facts
Inspection period: 5
Plan of Correction submission date: May 13, 2019
Re-visit date: May 29, 2019
Civil monetary penalty: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Phillip B. Moser | Regional Director of Operations | Signed as Respondent agreeing to Consent Order |
Inspection Report
Enforcement
Deficiencies: 3
Date: Jan 8, 2018
Visit Reason
The Department conducted a complaint and annual licensure survey at Chandler House from January 8, 2018 through January 11, 2018.
Findings
The facility failed to administer or document insulin administration properly for Resident #5 and failed to administer medications according to the plan of care for Residents #8 and #9. An unlicensed person administered medications in the secured unit, violating licensing rules.
Deficiencies (3)
Rule 1200-08-25-.07(5)(b) requires all drugs to be administered by a licensed professional according to the resident's plan of care. The facility allowed an unlicensed person to administer medications, including controlled substances, in the secured unit.
The facility failed to administer or document insulin administration for Resident #5 consistently, with blood sugar checks and sliding scale insulin documented inconsistently from March to July 2017.
Medications for Residents #8 and #9 were not administered according to the plan of care, with documented late medication administration observed.
Report Facts
Civil monetary penalty: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Michelle Adams | Administrator | Named as Respondent and signatory to the Consent Order. |
| Caroline R. Tippens | Assistant General Counsel | Signed the Consent Order on behalf of the Tennessee Department of Health. |
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