Deficiencies (last 3 years)
Deficiencies (over 3 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% better than Tennessee average
Tennessee average: 4.4 deficiencies/year
Deficiencies per year
4
3
2
1
0
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 15, 2024
Visit Reason
Commission surveyors conducted a Life Safety survey at Foxbridge Assisted Living and Memory Care on or about October 15, 2024.
Findings
The facility failed to conduct required fire drills for each ACLF work shift in each separate building for the first three quarters of 2024. The Administrator admitted that the fire drills were not conducted as required.
Deficiencies (1)
Tenn. Comp. R. and Regs. 0720-26-.10(3)(a) [Life Safety] requires fire drills for each ACLF work shift in each separate building at least quarterly. The facility failed to conduct fire drills for all shifts in the Pine, Magnolia, and Willow buildings for the first three quarters of 2024.
Report Facts
Civil Monetary Penalty: 1000
Time period: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Hall | Administrator | Admitted that the fire drills were not conducted as required. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 4, 2019
Visit Reason
An annual health licensure survey was conducted on June 4, 2019, to assess compliance with state laws and regulations at Foxbridge Assisted Living & Memory Care.
Findings
Surveyors observed violations related to dietary services, including discrepancies between residents' diet orders and the facility's diet manual. The facility's licensed dietician had placed a resident on an inappropriate diet, and the diet manual lacked required therapeutic diet listings.
Deficiencies (2)
Rule 1200-08-25.07(c)(3)(ii) Dietary services: The facility failed to ensure menus met residents' nutritional needs according to recognized dietary practices and practitioner orders.
Rule 1200-08-25.07(c)(3)(iii) Dietary services: The facility did not have a current therapeutic diet manual approved by the dietician readily available to all personnel.
Report Facts
Civil monetary penalties: 1000
Civil monetary penalties count: 2
Penalty amount per violation: 500
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 20, 2018
Visit Reason
The inspection was conducted as a complaint investigation following an incident involving Resident #1 who was found outside in the heat, unresponsive and dehydrated, leading to a complaint survey on August 20-22, 2018.
Complaint Details
The complaint was substantiated based on interviews and medical record review from the August 20-22, 2018 survey. Resident #1 was found outside on June 6, 2018, dehydrated and unresponsive during a heat advisory. The facility was cited for failure to provide safety to Resident #1.
Findings
The Department substantiated the complaint that the facility failed to provide a safe environment for Resident #1, who suffered heat stroke and dehydration after being left outside during a heat advisory. The facility was cited for failure to train staff on heat advisory policies and for not providing adequate documentation regarding the incident.
Deficiencies (1)
Failure to provide a safe environment for Resident #1, who was left outside in the heat and suffered heat stroke and dehydration. The facility did not train all staff on heat advisory policies during a Heat-Advisory In-Service.
Report Facts
Civil monetary penalty: 3000
Civil monetary penalty: 1500
Outstanding practice monitoring fees: 2669.8
Minutes Resident #1 was outside: 13
Days between incident and APS investigation letter: 7
Days between APS investigation letter and facility response: 1
Days between incident and complaint survey: 75
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