Inspection Reports for Gallatin Center for Rehabilitation and Healing
438 N Water Ave, Gallatin, TN 37066, United States, TN, 37066
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
82% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 9
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, medication management, activities of daily living, dental services, infection control, and pharmaceutical services.
Findings
The facility was found deficient in multiple areas including failure to safeguard residents' personal funds, medication misappropriation, inadequate personal hygiene assistance, failure to follow physician medication orders, improper destruction of narcotics, improper medication storage, failure to provide dental services, inaccurate medical records, and lapses in infection control practices.
Deficiencies (9)
Failed fiduciary responsibility in holding, safeguarding, managing, and accounting for deposited personal funds for 13 of 80 sampled residents with balances exceeding limits.
Failed to ensure residents' rights to be free from misappropriation of property due to diversion of medications including controlled substances for 3 residents.
Failed to provide adequate personal hygiene and bathing for 2 of 4 residents reviewed for activities of daily living.
Failed to follow physician's orders related to narcotic medication administration for 4 residents, resulting in medication errors.
Failed to properly destroy narcotic medications for 1 resident as required by facility policy.
Failed to ensure medications were properly stored when there was opened and undated medication on medication cart.
Failed to provide dental services for 1 resident; resident was not brought to scheduled dental appointments and documentation was lacking.
Failed to maintain accurate medical records related to dental appointments for 1 resident reviewed for dental services.
Failed to ensure proper infection control practices were followed when 1 staff member failed to disinfect reusable equipment and perform hand hygiene, and 2 staff members failed to wear PPE in isolation rooms.
Report Facts
Residents with personal fund overages: 13
Residents reviewed for medication misappropriation: 13
Residents reviewed for ADL bathing: 4
Residents reviewed for narcotic medication administration: 13
Residents reviewed for dental services: 2
Medication errors by LPN J: 10
Days Resident #81 not offered bathing: 35
Days Resident #131 not offered bathing: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN I | Registered Nurse | Named in medication diversion and misappropriation findings. |
| LPN DD | Licensed Practical Nurse | Named in medication administration errors, narcotic destruction failure, infection control lapses. |
| LPN J | Licensed Practical Nurse | Named in medication administration errors. |
| RN FF | Registered Nurse | Named in infection control lapses. |
| CNA EE | Certified Nurse Assistant | Named in infection control lapses. |
| Regional Business Office Consultant | Interviewed regarding awareness of resident trust fund overages. | |
| Director of Nursing | Director of Nursing | Interviewed regarding medication errors, infection control, and dental services. |
| Administrator | Administrator | Interviewed regarding medication errors, dental services, and narcotic destruction. |
| Medical Director | Medical Director | Interviewed regarding medication errors and expectations for nursing staff. |
| LPN Manager U | Licensed Practical Nurse Manager | Interviewed regarding medication storage and disposal. |
| Social Service Director | Social Service Director | Interviewed regarding dental services and documentation. |
Inspection Report
Routine
Deficiencies: 7
Date: Apr 28, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, environment, abuse investigations, care planning, wound care, IV administration, psychotropic medication use, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe, clean, and homelike environment in resident rooms, inadequate investigation of alleged misappropriation of resident property, failure to conduct care plan conferences for several residents, improper wound dressing maintenance, lack of documentation and proper care for peripheral IV catheter, failure to evaluate and monitor psychotropic medication use, and improper storage of oral hygiene equipment.
Deficiencies (7)
Failed to ensure a safe, clean, comfortable and homelike environment in 9 of 106 rooms observed, including issues with cleanliness, broken laminate with sharp edges, pungent odors, and broken call light devices.
Failed to conduct a thorough investigation in response to allegations of misappropriation for 1 of 21 sampled residents.
Failed to conduct care plan conferences for 4 of 56 sampled residents reviewed.
Failed to ensure a wound dressing was maintained according to professional standards of practice for 1 of 9 sampled residents.
Failed to ensure a Peripheral IV catheter was administered and maintained according to professional standards of practice for 1 of 3 sampled residents.
Failed to evaluate and have behavior monitoring for 1 of 5 sampled residents for unnecessary psychotropic medications.
Failed to properly store oral hygiene equipment in a sanitary manner for 5 of 106 resident rooms observed.
Report Facts
Rooms observed with environment deficiencies: 9
Residents sampled for abuse review: 21
Residents sampled for care plan review: 56
Residents sampled for wound care review: 9
Residents sampled for IV care review: 3
Residents sampled for psychotropic medication review: 5
Rooms observed with improper oral hygiene equipment storage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #10 | Certified Nursing Assistant | Confirmed chairs blocked closet access and improper storage of supplies; confirmed unlabeled toothbrush and denture cup storage |
| Environmental Service Supervisor | Environmental Service Supervisor | Confirmed presence of substances on doors and walls; confirmed rooms and bathrooms were not properly cleaned |
| Maintenance Director | Maintenance Director | Observed and confirmed peeling paint, exposed splintered wood, broken laminate, and broken call light boxes |
| Licensed Practical Nurse #17 | Licensed Practical Nurse | Reported on missing debit card and room search for Resident #118 |
| Housekeeper #2 | Housekeeper | Reported completion of cleaning in rooms #324-#330 |
| Registered Nurse/Unit Manager #6 | Registered Nurse/Unit Manager | Confirmed no documentation of peripheral IV insertion and improper oral hygiene equipment storage |
| Wound Care Nurse #1 | Wound Care Nurse | Observed frayed and dirty wound dressing; reviewed treatment records |
| Licensed Practical Nurse #18 | Licensed Practical Nurse | Reviewed EHR and confirmed no documentation of peripheral IV insertion |
| Nurse Practitioner #1 | Nurse Practitioner | Confirmed Resident #136 was closely monitored weekly; ordered discontinuation of IV fluids |
| Social Worker | Social Worker | Confirmed lack of care plan conferences for several residents |
| Administrator | Administrator | Confirmed no thorough investigation of missing debit card and lack of reporting to law enforcement |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Mar 26, 2019
Visit Reason
The inspection was conducted based on complaints and concerns regarding wound care, respiratory care, nursing competencies, medication management, drug regimen reviews, medication storage, and infection control practices at the facility.
Complaint Details
The visit was complaint-related, triggered by concerns about wound care, respiratory care, nursing competencies, medication management, and infection control. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to follow physician's orders for wound care dressing changes, inadequate respiratory care, lack of nursing competencies in pressure ulcer staging, failure to ensure pharmacist recommendations for psychotropic medication stop dates, absence of psychotropic drug side effect monitoring, improper medication storage and labeling, and failure to maintain sanitary ice storage and scoop.
Deficiencies (8)
Failed to follow physician's orders related to wound care dressing change for 1 resident (#133).
Failed to provide necessary respiratory care for 2 residents (#24 and #482) receiving respiratory services.
Failed to ensure nursing staff have the knowledge and competencies for staging pressure ulcers for 1 resident (#100).
Pharmacist failed to make recommendations for a stop date related to a prn anti-psychotic medication for 1 resident (#121).
Facility failed to have psychotropic/antipsychotic drug side effect or behavior monitoring in place for 1 resident (#121).
Failed to provide an adequate diagnosis and a 14 day stop date for a prn anti-psychotic drug for 1 resident (#121).
Failed to refrigerate and properly store medications on 4 of 12 medication carts.
Failed to maintain ice storage container and scoop in a sanitary manner.
Report Facts
Residents receiving wound care: 15
Residents receiving respiratory services: 37
Residents with staging pressure ulcers: 15
Residents reviewed receiving anti-psychotic medications: 32
Medication carts inspected: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Wound care nurse | Observed wound care performed for Resident #133. |
| Licensed Practical Nurse #9 | Confirmed nebulizer and tubing needed to be in the bag when not in use for Residents #24 and #482. | |
| Director of Nursing | Director of Nursing | Confirmed expectations for following physician's orders and medication storage practices; confirmed lack of wound competencies and psychotropic medication monitoring. |
| Regional Wound Care Consultant | Interviewed regarding wound assessment and competencies. | |
| Pharmacist | Interviewed regarding monthly drug regimen reviews and recommendations for Resident #121. | |
| Resident #121's Hospice Physician | Hospice Physician | Interviewed regarding psychotropic medication monitoring and diagnosis. |
| Licensed Practical Nurse #1 | Observed medication cart with improperly stored medications. | |
| Licensed Practical Nurse #5 | Observed medication cart with improperly stored medications. | |
| Licensed Practical Nurse #7 | Observed medication cart with improperly stored medications. | |
| Licensed Practical Nurse #8 | Observed medication cart with improperly stored medications. |
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