Deficiencies (last 3 years)
Deficiencies (over 3 years)
11.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
166% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 27, 2023
Visit Reason
The inspection was conducted due to complaints related to abuse and injury of unknown origin involving residents at the facility.
Complaint Details
The complaint investigation involved allegations of verbal abuse by dietary staff toward Resident #4 and failure to report and investigate injuries of unknown origin for Resident #1. The investigation included interviews with residents, staff, and administrators, and review of facility policies and records.
Findings
The facility failed to protect a resident from verbal abuse by dietary staff, failed to timely report suspected abuse and injuries of unknown origin to the State Agency, failed to conduct a thorough investigation of an injury of unknown origin, and failed to ensure proper transfer methods were used for a resident who fell out of their wheelchair.
Deficiencies (4)
Failed to protect Resident #4 from verbal abuse by Dietary Staff (DS) #3 who used profanity and a derogatory name.
Failed to timely report allegations of abuse and injuries of unknown origin to the State Agency within two hours for Resident #1.
Failed to ensure a thorough investigation of an injury of unknown origin for Resident #1.
Failed to ensure proper transfer methods were used for Resident #1 who flipped out of their chair.
Report Facts
Residents reviewed for abuse: 7
Residents affected: 1
Residents affected: 1
Date of injury occurrence: 2023
Date of verbal abuse occurrence: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DS #3 | Dietary Staff | Named in verbal abuse finding and disciplinary warning related to incident with Resident #4 |
| LPN #4 | Licensed Practical Nurse | Documented injury and progress notes for Resident #1 |
| RN #2 | Registered Nurse | Reported Resident #1 fall and injury |
| CNA #9 | Certified Nursing Assistant | Reported Resident #1 fall and assisted with transfer |
| CNA #10 | Certified Nursing Assistant | Assisted with Resident #1 transfer and provided statement |
| Resident #5 | Resident Witness | Witnessed verbal abuse incident involving Resident #4 and DS #3 |
| Administrator | Facility Administrator | Interviewed regarding abuse and injury investigations |
| DON | Director of Nursing | Interviewed regarding abuse and injury investigations |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 15, 2023
Visit Reason
The inspection was conducted due to allegations of resident abuse and failure to report investigative outcomes within the required timeframe, as well as concerns related to blood glucose monitoring for a resident.
Complaint Details
The complaint investigation involved allegations of resident abuse for five residents. The facility failed to report the outcome of investigations to the State Agency within 5 working days. The Director of Nursing and Administrator confirmed the failure to report to Adult Protective Services or law enforcement.
Findings
The facility failed to report the results of abuse investigations involving five residents within five working days as required by state law. Additionally, the facility failed to monitor and document blood glucose levels as prescribed for one resident. Interviews confirmed the failures in reporting and monitoring.
Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities within 5 working days for 3 of 3 allegations involving 5 residents.
Failed to monitor blood glucose levels as prescribed for 1 of 3 residents reviewed related to blood glucose monitoring.
Report Facts
Residents involved in abuse allegations: 5
Dates with missing blood glucose documentation: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed the outcome of the facility's investigation was not reported to the State Incident Reporting System within 5 working days. | |
| Administrator | Confirmed responsibility for reporting allegations of abuse and acknowledged failure to report the outcome of the investigation and alleged violations to APS or law enforcement. |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Jun 15, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements including resident rights, abuse reporting, resident assessments, care planning, medication management, nutrition, respiratory care, infection control, and other areas.
Findings
The facility was found deficient in multiple areas including failure to inform residents about advance directives, failure to timely report abuse investigations, incomplete and inaccurate resident assessments, failure to conduct care plan meetings and revise care plans timely, failure to monitor blood glucose and weights as ordered, failure to provide appropriate respiratory care, failure to monitor side effects of antipsychotic medications, failure to properly label and store medications, failure to meet residents' food preferences, and failure to maintain an effective infection prevention and control program including Legionella surveillance.
Deficiencies (12)
Failed to inform or provide written information regarding residents' rights to formulate an advance directive for 12 of 24 residents reviewed.
Failed to timely report investigative outcomes of alleged abuse within 5 working days for 3 of 3 allegations reviewed involving 5 residents.
Failed to complete admission Minimum Data Set (MDS) assessment within regulatory time frames for 1 of 20 residents reviewed.
Failed to accurately assess residents for hospice care for 2 of 2 residents reviewed.
Failed to conduct care plan meetings for 3 of 8 residents and failed to revise care plan timely for 1 of 19 residents reviewed.
Failed to monitor blood glucose levels as prescribed for 1 of 3 residents reviewed.
Failed to follow facility policy for monitoring weights for 2 of 5 residents reviewed for nutrition.
Failed to ensure appropriate respiratory and tracheostomy care for 1 of 1 resident reviewed, including lack of emergency equipment and monitoring.
Failed to monitor for side effects of antipsychotic medications for 2 of 5 residents reviewed.
Failed to ensure medications were properly labeled and stored, including missing identifiers on insulin pen and lack of refrigerator temperature monitoring.
Failed to ensure food preferences and menu choices were met for 2 of 8 residents reviewed.
Failed to maintain and monitor an effective infection prevention and control program including Legionella surveillance for 3 of 3 residents reviewed.
Report Facts
Residents affected: 12
Residents affected: 5
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Confirmed lack of order for monitoring antipsychotic side effects for Resident #44 |
| DON | Director of Nursing | Confirmed lack of monitoring for antipsychotic side effects for Resident #44 and #391; confirmed blood glucose monitoring orders should be followed; confirmed medication labeling and storage deficiencies |
| Regional MDS Nurse | Confirmed late submission of admission MDS for Resident #66 | |
| Social Worker | Confirmed missing care plan meeting documentation for Residents #9, #44, and #50 | |
| Registered Dietitian | Confirmed weight management issues and nutrition assessment deficiencies for Resident #20 and #41 | |
| Unit Manager #1 | Confirmed tracheostomy care deficiencies for Resident #37 | |
| LPN #3 | Licensed Practical Nurse | Confirmed insulin pen labeling deficiencies |
| Administrator | Confirmed lack of effective Legionella surveillance program and failure to timely report abuse investigations | |
| Nurse Practitioner #1 | Confirmed physician orders for weight monitoring should be followed for Resident #20 |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Jul 19, 2021
Visit Reason
The inspection was conducted due to a complaint investigation related to resident abuse, wandering, and behaviors in a nursing home.
Complaint Details
The complaint investigation was triggered by allegations of resident abuse, wandering, and inadequate care for residents with dementia and behaviors. The investigation found multiple deficiencies including a resident-to-resident altercation resulting in death, inadequate supervision, failure to implement care plans, and insufficient staff training.
Findings
The facility failed to ensure adequate supervision and interventions for residents with physically aggressive and wandering/exit-seeking behaviors, resulting in immediate jeopardy when Resident #80 pushed Resident #81 causing serious injury and death. Multiple residents exhibited unsafe behaviors without appropriate care plans or supervision. The facility also failed to provide adequate staff training and oversight, and had deficiencies in infection control, medication administration, and care planning.
Deficiencies (11)
Failure to protect residents from abuse and ensure adequate supervision and interventions for residents with aggressive and wandering behaviors.
Failure to complete comprehensive assessments timely for Resident #252.
Failure to ensure accuracy of Minimum Data Set related to oxygen and pressure ulcers for Residents #73 and #87.
Failure to develop and revise care plans based on resident needs and current interventions for Residents #34, #87, #89, and #303.
Failure to complete timely fall investigation for Resident #99.
Failure to ensure agency and facility staff had appropriate competencies and training to care for residents with dementia and behaviors, resulting in immediate jeopardy.
Failure to procure food from approved sources and serve food under sanitary conditions.
Failure to provide and implement an infection prevention and control program, including proper isolation and hand hygiene practices.
Failure to ensure safe medication administration practices, including handling medications with bare hands and proper PEG tube medication administration.
Failure to administer the facility in a manner that enables effective and efficient use of resources to ensure resident safety and care, resulting in immediate jeopardy.
Failure to set up an effective Quality Assurance Performance Improvement (QAPI) program to monitor and improve care related to resident abuse, behaviors, and dementia, resulting in immediate jeopardy.
Report Facts
Residents reviewed: 28
Residents affected by abuse and behavior deficiencies: 6
Residents affected by infection control deficiencies: 3
Residents affected by medication administration deficiencies: 2
Residents affected by pressure ulcer care deficiencies: 3
Residents affected by fall investigation deficiency: 1
Staff observed with improper food handling: 3
Staff observed with improper medication handling: 2
Behavior monitoring audit frequency: 4
Behavior monitoring audit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reported Resident #34 running over surveyor and others with wheelchair |
| LPN #2 | Licensed Practical Nurse | Observed washing resident's hands then wiping dining table with same cloth |
| LPN #3 | Licensed Practical Nurse | Failed to perform hand hygiene during wound care |
| LPN #4 | Licensed Practical Nurse | Failed to check PEG tube placement, administered medications improperly, touched medications with bare hands |
| RN #1 | Registered Nurse | Served food under unsanitary conditions |
| RN #2 | Registered Nurse | New hire with no orientation, unsure of medication wasting policy |
| CNA #1 | Certified Nursing Assistant | Witnessed resident behaviors and interactions |
| CNA #2 | Certified Nursing Assistant | Handled food with bare hands, witnessed resident behaviors |
| CNA #5 | Certified Nursing Assistant | New hire with no orientation or education on dementia or behaviors |
| CNA #6 | Certified Nursing Assistant | New hire with no orientation or education on dementia or behaviors |
| Administrator | Facility Administrator | Interviewed regarding facility administration, agency staff orientation, and QAPI |
| Director of Nursing | Director of Nursing | Interviewed regarding staff training, QAPI, and care oversight |
| Detective #1 | Police Detective | Interviewed regarding criminal charge against Resident #80 |
Inspection Report
Routine
Deficiencies: 6
Date: Nov 19, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, safety, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to provide adequate nail care for residents, unsecured sharps and chemicals posing accident hazards, improper catheter care, medication errors exceeding acceptable rates, unsecured and expired medications, and loose handrails in hallways.
Deficiencies (6)
Failure to provide nail care for 3 of 3 sampled residents unable to perform activities of daily living.
Failure to ensure environment was free of accident hazards due to unsecured sharps and chemicals in multiple resident rooms, storage rooms, supply rooms, and bathrooms.
Failure to maintain indwelling urinary catheter drainage bag off the floor for 1 sampled resident.
Medication error rate exceeded 5 percent with 4 errors out of 31 opportunities observed for 1 nurse.
Failure to ensure medications were not stored past expiration, were dated when opened, medication carts kept secure, and medications stored properly in multiple medication storage areas.
Failure to maintain firmly secured handrails in hallway; handrails were loose and hanging off the wall.
Report Facts
Residents sampled for nail care deficiency: 3
Sharps and chemicals unsecured in resident rooms: 2
Sharps and chemicals unsecured in storage rooms: 1
Sharps and chemicals unsecured in supply rooms: 2
Sharps and chemicals unsecured in common resident bathrooms: 2
Medication errors observed: 4
Medication error rate: 12.90322581
Tuberculin vaccine open date: 8
Tuberculin vaccine expiration after opening: 60
Number of disposable razors observed unsecured: 200
Number of denture cleanser tablets observed unsecured: 336
Number of tuberculin syringes/needles observed unsecured: 200
Number of skin prep wipes observed unsecured: 150
Number of needles observed unsecured: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in medication error finding with 4 errors observed |
| LPN #6 | Licensed Practical Nurse | Interviewed regarding Resident #30's toenails |
| LPN #2 | Licensed Practical Nurse | Interviewed about unsecured razors and storage rooms |
| LPN #5 | Licensed Practical Nurse | Interviewed about Resident #55's toenails |
| CNA #3 | Certified Nursing Assistant | Interviewed about Resident #55's toenails |
| CNA #5 | Certified Nursing Assistant | Interviewed about locking storage rooms |
| RN #1 | Registered Nurse | Interviewed about treatment cart security |
| RN #2 | Registered Nurse | Interviewed about medication cart security |
| DON | Director of Nursing | Interviewed multiple times regarding nail care, medication security, catheter care, and storage room security |
| Administrator | Administrator | Interviewed about handrail safety |
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