Inspection Reports for
Creekside Center for Rehabilitation & Healing
306 West Due West Avenue, Madison, TN, 37115-4511
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
59% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 20, 2018
Visit Reason
The Department of Health conducted a complaint survey at Prestige Assisted Living of Loudon Co from June 12, 2018 through June 20, 2018 due to allegations of deficient practices affecting resident health, safety, or welfare.
Complaint Details
The complaint investigation was substantiated, resulting in the suspension of admissions due to deficient practices and conditions found during the survey.
Findings
The investigation found conditions at the facility that were or likely to be detrimental to resident health, safety, or welfare due to violations in multiple areas including administration, infection control, medication management, admissions and transfers, life safety, and resident records.
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 11
Date: Jun 12, 2018
Visit Reason
Surveyors conducted an annual survey and investigation of seven complaints at Prestige Assisted Living of Loudon between June 12-20, 2018.
Findings
The facility failed to ensure safety related to smoking and oxygen use, failed to provide appropriate hospice certifications, failed to update care plans for residents with escalating behaviors, and had issues with medication administration and disposal. Unsafe smoking practices resulted in a fatal fire. The facility was placed under suspension of admissions and required to submit plans of correction.
Deficiencies (11)
The facility failed to obtain physician certification that hospice care was appropriate for multiple residents on hospice.
Plans of care did not address oxygen use and smoking risks, and no education on fire risk was documented.
The facility failed to update care plans for residents with escalating verbal and physical behaviors posing imminent threats.
The facility failed to immediately discharge residents who posed imminent threats to self or others.
Unsafe smoking practices led to a fatal fire causing the death of Resident #7.
The facility failed to follow admission agreements regarding safe smoking for multiple residents.
Certified clinical medical assistants administered medications instead of licensed nurses for all residents.
The facility failed to administer a Fentanyl patch for six days after it was ordered.
Medications were not administered timely by a non-licensed technician, causing decline in a resident's condition.
The facility failed to document medication disposal and narcotic counts properly after resident discharge.
The facility failed to maintain a safe, clean, and sanitary environment, with observations of insects and cobwebs.
Report Facts
Complaints investigated: 7
Residents currently in facility: 40
Civil monetary penalty: 10000
Days for plan of care development: 5
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 15, 2016
Visit Reason
The initial visit was an annual survey conducted from October 11 through October 24, 2016, which resulted in suspension of admissions due to deficient practices. A follow-up survey was conducted November 14-15, 2016, to determine if deficiencies were corrected.
Findings
The follow-up survey found that the deficient practices and conditions detrimental to resident health, safety, or welfare had been corrected, and the facility returned to substantial compliance as of November 15, 2016.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 11, 2016
Visit Reason
A complaint survey was conducted at Creekside Health and Rehab from October 11 through October 24, 2016, to investigate alleged deficient practices detrimental to the health, safety, or welfare of residents.
Complaint Details
The complaint survey was completed on November 9, 2016. The violations were substantiated and deemed serious enough to warrant suspension of admissions and a monetary penalty.
Findings
The investigation revealed violations of licensure statutes and regulations considered detrimental to resident health, safety, or welfare. As a result, the Commissioner suspended admissions and imposed a Type A civil monetary penalty of $6,100.
Report Facts
Civil monetary penalty amount: 6100
Inspection Report
Enforcement
Deficiencies: 3
Date: Aug 3, 2016
Visit Reason
A licensure and complaint survey was completed on August 3, 2016, to investigate compliance with state laws and regulations at Prestige Assisted Living of Loudon.
Findings
The survey found serious violations resulting in endangerment to the health, safety, and welfare of residents. Deficiencies included failure to ensure medications were administered by licensed professionals, improper medication storage, and failure to develop and update plans of care for residents.
Deficiencies (3)
Rule 1200-08-25-.07: Respondent failed to ensure all drugs and biologicals were administered by a licensed professional for four residents reviewed.
Rule 1200-08-25-.07: Respondent failed to store all medications to prevent residents from obtaining others' medications.
Rule 1200-08-25-.12: Respondent failed to develop a plan of care within five days of admission and failed to update plans semi-annually for five residents, including hospice residents.
Report Facts
Civil monetary penalties: 1500
Residents reviewed: 4
Residents reviewed: 5
Hospice residents reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nikki Zaveri | Administrator | Signed the consent order as respondent. |
| Kyonzie Hughes Toombs | Deputy General Counsel | Signed the consent order on behalf of Tennessee Department of Health. |
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