Deficiencies (last 4 years)
Deficiencies (over 4 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% better than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Annual Inspection
Deficiencies: 3
Mar 25, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, and notification of significant changes in condition for residents at Island Home Park Health and Rehab.
Findings
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, failed to refer two residents to the state PASRR agency after new mental health diagnoses, and failed to timely revise the care plan for one resident after discontinuation of enteral feeding. These deficiencies were associated with minimal harm or potential for actual harm affecting a few residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure MDS assessments were accurate for 3 residents (Resident #33, #40, and #55). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to refer 2 residents (Resident #15 and Resident #32) to the state designated PASRR agency after new mental health diagnoses. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise the care plan timely for 1 resident (Resident #28) after discontinuation of enteral feeding. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for MDS assessments: 18
Residents affected by inaccurate MDS assessments: 3
Residents reviewed for PASRR: 7
Residents not referred to PASRR agency: 2
Residents' care plans reviewed: 18
Residents affected by untimely care plan revision: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MDS Licensed Practical Nurse (LPN) B | Confirmed inaccuracies in MDS assessments for Residents #33 and #55 and care plan revision for Resident #28 | |
| MDS Licensed Practical Nurse (LPN) C | Confirmed inaccuracies in MDS assessments for Residents #33 and #55 | |
| Dialysis Nurse D | Confirmed Resident #40 received dialysis treatments | |
| Director of Nursing (DON) | Confirmed Resident #40 received dialysis treatments and confirmed failure to refer Residents #15 and #32 to PASRR agency | |
| Wound Care Nurse | Confirmed Resident #55 had a wound over a sacral scar | |
| Licensed Practical Nurse (LPN) A | Stated Resident #28 previously received enteral feedings and had not received them for a long time | |
| LPN Supervisor | Stated Resident #28's enteral feedings were discontinued and care plan was not revised |
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 8, 2024
Visit Reason
The inspection was conducted due to complaints regarding physical abuse of a resident and misappropriation of resident property at Island Home Park Health and Rehab.
Findings
The facility failed to prevent physical abuse of one resident (Resident #1) when a CNA touched the resident's face during care, resulting in the CNA's termination. Additionally, the facility failed to protect another resident's (Resident #3) belongings when $400 was taken from the resident's room; the facility reimbursed the resident but could not identify the responsible party.
Complaint Details
The complaint investigation substantiated physical abuse of Resident #1 by CNA D, who was suspended and terminated following the incident. The investigation also substantiated misappropriation of $400 from Resident #3's belongings; the facility reimbursed the resident but could not determine who was responsible.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to protect Resident #1 from physical abuse by a Certified Nursing Assistant who touched the resident's face during care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect Resident #3 from misappropriation of $400 from the resident's belongings. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for abuse: 8
Residents affected by abuse deficiency: 1
Residents sampled for misappropriation: 4
Residents affected by misappropriation deficiency: 1
Amount misappropriated: 400
Date of abuse incident: Jul 11, 2024
Date of CNA termination: Jul 12, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in physical abuse finding involving Resident #1; suspended and terminated |
| LPN B | Licensed Practical Nurse | Assessed Resident #1 after abuse incident and notified supervisors |
| LPN E | Licensed Practical Nurse Supervisor | Notified of abuse incident and assessed Resident #1 |
| Director of Nursing | Director of Nursing (DON) | Involved in investigation and suspension of CNA D |
| Administrator | Facility Administrator | Notified of abuse and misappropriation incidents; confirmed findings |
| Social Services Director | Social Services Director (SSD) | Interviewed Resident #1 post-incident |
| LPN A | Licensed Practical Nurse | First person notified about missing money from Resident #3 |
Inspection Report
Deficiencies: 0
Dec 8, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Island Home Park Health and Rehab, summarizing the results of a regulatory survey completed on December 8, 2021.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 31, 2019
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Island Home Park Health and Rehab, summarizing the findings from the survey completed on 07/31/2019.
Findings
No health deficiencies were found during the survey.
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