Inspection Reports for
Lafollette Court Assisted Living Community, Inc
139 N. Massachusetts Avenue, Lafollette, TN, 37766
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
195% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Enforcement
Deficiencies: 26
Date: Dec 14, 2023
Visit Reason
This document is an Order of Summary Suspension issued by the Tennessee Board for Licensing Health Care Facilities due to severe violations and misconduct at Vivant Healthcare nursing homes in Murfreesboro and Shelbyville. The suspension is based on multiple regulatory breaches and threats to resident health, safety, and welfare.
Complaint Details
The complaint survey conducted from October 16, 2023, to November 9, 2023, identified six ongoing immediate jeopardies related to medication errors and infection control. The facility failed to notify physicians of critical blood glucose levels for eight residents and failed to provide proper nutrition and medication management.
Findings
The Board found numerous violations including failure to implement infection control, inadequate resident care, drug diversion, failure to maintain proper staffing and payroll, unsafe living conditions, and failure to comply with life safety codes. Immediate jeopardy citations and civil monetary penalties were imposed. The facilities were decertified by CMS and ordered to transfer all residents by February 12, 2024.
Deficiencies (26)
The facility failed to implement transmission-based precautions and a qualified infection control program, including improper use of PPE and contaminated water leakage.
The facility failed to ensure comprehensive care plans, oversight, and a Quality Assurance and Process Improvement Committee for infection control.
The Director of Nursing allowed a cognitively impaired employee to work, posing danger to self and others.
The facility failed to properly assess and treat a resident with a broken neck, resulting in harm and pain.
Nursing staff failed to perform neurological exams for residents with head injuries.
The facility imposed civil monetary penalties totaling $1,250 for various violations.
Payroll failures caused staffing and food shortages, non-payment to medical director, and disconnection of TV services for 79 residents.
Food services were disrupted due to unpaid vendors, resulting in poor quality and non-palatable food affecting 74 residents on special diets.
Life safety survey found 75 boxes of flooring left uninstalled due to non-payment, and blocked exits in the memory care unit.
Complaint survey revealed multiple immediate jeopardies including failure to notify physicians of critical blood glucose levels for 8 residents.
The facility failed to provide proper enteral nutrition for 2 residents, causing significant weight loss.
Extensive drug diversion was found, including missing narcotics and improper narcotic count handling by the Assistant Director of Nursing.
The Director of Nursing was found to be using illegal substances and was terminated; her nursing privileges were suspended for at least four years.
Resident #11 was left unsupervised and eloped twice from the facility, posing safety risks.
The facility failed to properly label and manage insulin pens for multiple residents, including expired and unlabeled pens.
The governing body failed to ensure sufficient supply of enteral feeding formula and to employ a registered dietician.
The governing body failed to report and investigate medication misappropriation and failed to notify physicians of residents' blood glucose issues.
The facility failed to submit credible allegations of removal after multiple attempts to remove immediate jeopardy.
A former nurse pled guilty to theft of patient narcotics from the facility and surrendered her nursing license.
Revisit survey found ongoing immediate jeopardies including medication errors and infection control failures.
The facility failed to have petty cash on hand to address resident needs.
The facility was unable to make payroll and had outstanding nursing home assessment fees totaling over $187,000.
Viviant of Shelbyville experienced flooding due to burst sprinkler pipes, causing evacuation of 78 residents and closure for several months.
During closure, 23 complaints were outstanding and the facility nearly reached mandatory termination.
Upon reopening, only 2 residents were readmitted and the call light system was broken and not repaired.
Resident #24 fell multiple times resulting in a broken femur; the facility failed to revise care plans or investigate the cause.
Report Facts
Residents affected by transmission-based precaution failure: 8
Civil Monetary Penalties: 1250
Residents affected by TV disconnection: 79
Residents affected by poor diet quality: 74
Boxes of flooring left uninstalled: 75
Immediate jeopardies identified: 6
Insulin dependent residents with notification failures: 8
Insulin pens expired: 3
Insulin pens unlabeled or no expiration: 17
Residents evacuated due to flooding: 78
Complaints outstanding during closure: 23
Residents readmitted after reopening: 2
Nursing home assessment fees outstanding: 187622.81
Nursing home assessment fees outstanding: 355390.16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Beth Galyon | Former Nurse | Pled guilty to theft of patient narcotics from a resident |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 9, 2023
Visit Reason
The Health Facilities Commission conducted a complaint survey at Viviant Healthcare of Murfreesboro from January 9 through January 20, 2023, to investigate alleged violations impacting patient care.
Complaint Details
The complaint investigation was completed on February 3, 2023, and substantiated violations leading to civil monetary penalties.
Findings
The survey revealed violations of licensure statutes and regulations related to Basic Services Infection Control, resulting in the imposition of two Type B and one Type C Civil Monetary Penalties.
Report Facts
Type B Civil Monetary Penalties: 2
Type C Civil Monetary Penalties: 1
Total Civil Monetary Penalty Amount: 1250
Penalty Payment Due Days: 5
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 14, 2021
Visit Reason
The inspection was conducted as a complaint survey triggered by allegations concerning the facility's compliance with licensure statutes and regulations.
Complaint Details
The complaint survey was substantiated, leading to findings of violations and a civil monetary penalty assessment.
Findings
The survey revealed violations of licensure statutes and regulations impacting patient care, resulting in the imposition of a Type B Civil Monetary Penalty for violations related to Resident Rights.
Report Facts
Civil Monetary Penalty amount: 500
Document
Deficiencies: 0
Date: Feb 17, 0532
Visit Reason
This document is a Consent Order related to disciplinary action and license status of Vivant Healthcare of Murfreesboro Skilled Nursing Facility following decertification by CMS and a summary suspension order.
Findings
The facility was decertified by CMS effective December 14, 2023, and the Board issued a Summary Suspension Order on that date. The Consent Order lifts the suspension but places the license on inactive status for one year, with conditions for reactivation and compliance.
Report Facts
License Number: 217
License Expiration Date: License expiration date is May 5, 2024.
Decertification Effective Date: CMS decertification effective December 14, 2023.
Inactive Status Duration: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathaniel Flinchbaugh | Deputy General Counsel | Signed the Consent Order on behalf of the Health Facilities Commission. |
| Samuel Goldner | Authorized Representative | Signed the Consent Order as the facility representative. |
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