Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 5
Aug 18, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to respiratory care, food safety, medical record maintenance, infection prevention, and vaccination procedures at the nursing facility.
Findings
The facility was found deficient in multiple areas including improper storage of nebulizer masks for residents, failure to maintain recommended temperatures for kitchen equipment, incomplete documentation of COVID-19 vaccine contraindication screening, failure to follow enhanced barrier precautions for a resident with an indwelling catheter, and failure to assess medical contraindications prior to influenza vaccinations for two residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to properly store nebulizer masks for 2 residents, leaving masks uncovered and not stored in labeled bags as per facility policy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure kitchen beverage cooler and high temperature dishwasher maintained recommended temperatures, with multiple out-of-range and omitted temperature logs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document assessment for contraindications to COVID-19 vaccines for 1 resident; screening questionnaire was incomplete. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure enhanced barrier precautions were followed for 1 resident with an indwelling urinary catheter; staff did not wear appropriate PPE and no signage was present. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assess medical contraindications prior to administering influenza vaccines for 2 residents; screening was not completed or documented. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled for nebulizer mask storage: 5
Temperature log dates with out-of-range dishwasher rinse temperatures: 7
Residents reviewed for immunizations: 5
Residents reviewed for enhanced barrier precautions: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed improper storage of nebulizer masks and incomplete vaccine screening documentation |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Confirmed placing nebulizer mask in bag after it was found uncovered |
| Dietary Manager | Dietary Manager (DM) | Responsible for reviewing temperature logs; confirmed missed out-of-range temperatures |
| Infection Preventionist | Infection Preventionist (IP) | Confirmed incomplete vaccine screening and failure to follow enhanced barrier precautions |
| Medical Director | Medical Director | Confirmed expectation for vaccine contraindication screening and no adverse reactions |
| Certified Nurse Assistant | Certified Nurse Assistant (CNA) F | Failed to wear appropriate PPE during care for resident with indwelling catheter |
| Registered Nurse Supervisor | Registered Nurse (RN) Supervisor | Confirmed resident was not on enhanced barrier precautions despite need |
| 200/300 Unit Manager | Unit Manager | Confirmed nebulizer mask storage was not in accordance with facility policy |
Inspection Report
Complaint Investigation
Deficiencies: 5
Jun 5, 2024
Visit Reason
The inspection was conducted to investigate complaints related to inaccurate resident assessments, failure to coordinate pre-admission screening and resident review (PASARR), incomplete care plans, and unsecured medications.
Findings
The facility failed to accurately complete Minimum Data Set (MDS) assessments for residents, failed to resubmit PASARR after new mental health diagnoses, failed to implement comprehensive care plans reflecting residents' mental health diagnoses, and failed to secure medications for a resident. These deficiencies affected a few residents and posed minimal harm or potential for harm.
Complaint Details
The visit was complaint-related, investigating issues including inaccurate MDS assessments, failure to resubmit PASARR screenings, incomplete care plans, and unsecured medications. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to accurately complete Minimum Data Set (MDS) assessments for 2 residents (Resident #25 and #11). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to resubmit a Pre-admission Screening and Resident Review (PASARR) after new mental health diagnoses were identified for 1 resident (Resident #44). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a Pre-admission Screening and Resident Review (PASARR) was accurate upon admission for 1 resident (Resident #11). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement a comprehensive care plan to reflect a Post Traumatic Stress Disorder (PTSD) diagnosis for 1 resident (Resident #24). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to secure medications for 1 resident (Resident #7), with medications found unsecured in the resident's bathroom. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for MDS assessments: 18
Residents reviewed for PASARR: 12
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
BIMS score: 9
BIMS score: 12
BIMS score: 6
BIMS score: 11
Medication quantities: 7
Medication quantities: 45
Medication quantities: 45
Medication quantities: 18.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse D | Licensed Practical Nurse | Confirmed Resident #25 received hospice services and confirmed medications in Resident #7's bathroom were not provided by the facility. |
| MDS Coordinator C | MDS Coordinator | Confirmed Resident #25 received hospice services and the quarterly MDS assessment did not include hospice services. |
| NP A | Nurse Practitioner | Diagnosed Resident #44 with Delusions and Adjustment Reaction with Anxiety and Depression. |
| Registered Nurse Minimum Data Set Coordinator A | Registered Nurse (RN) Minimum Data Set Coordinator | Confirmed Resident #44 was not referred for level 2 PASARR and confirmed Resident #11's admission PASARR screen was inaccurate. |
| Licensed Practical Nurse MDS Coordinator B | Licensed Practical Nurse (LPN) MDS Coordinator | Confirmed the comprehensive care plan for Resident #24 did not reflect the resident's active PTSD diagnosis or interventions. |
| Licensed Practical Nurse D | Licensed Practical Nurse (LPN) | Confirmed medications in Resident #7's bathroom were stored unsecured and not provided by the facility. |
| Director of Nursing | Director of Nursing (DON) | Confirmed Resident #7 was not assessed to self-administer medications and medications were not stored properly. |
| Registered Nurse Clinical Reimbursement Specialist | Registered Nurse (RN) Clinical Reimbursement Specialist | Confirmed MDS assessment was not coded accurately for Resident #11. |
Inspection Report
Annual Inspection
Deficiencies: 4
Jul 20, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, catheter care, fluid restrictions, and advance directives for residents at Life Care Center of East Ridge.
Findings
The facility failed to develop complete care plans for residents including radiation therapy and catheter use, failed to schedule required urology follow-ups, did not follow physician orders for fluid restrictions and weights, and had inaccuracies in residents' advance directive documentation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to develop and implement a complete care plan that meets all the resident's needs, including radiation therapy and catheter use. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow a physician's order in obtaining a follow-up urology appointment for an indwelling urinary catheter. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow physician's orders for fluid restrictions and daily weights for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain completed Physician Order for Scope of Treatment (POST) forms and accurate code status orders. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for care plans: 18
Residents reviewed for urinary catheters: 4
Residents reviewed for fluid restrictions: 3
Fluid restriction amount: 1500
Fluid restriction amount: 1800
Weights not obtained: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Named in relation to radiation therapy observation and fluid restriction documentation |
| Medical Director | Provided statements regarding care plan expectations, fluid restrictions, and resident assessments | |
| Administrator | Confirmed care plan deficiencies | |
| Director of Nursing | Director of Nursing | Confirmed care plan and follow-up appointment deficiencies, and inaccuracies in POST forms |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding fluid restriction awareness and resident weighing |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding resident weighing and fluid restriction awareness |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed regarding fluid restriction monitoring |
| Dietary Manager | Dietary Manager | Interviewed regarding fluid restriction calculations and communication with nursing |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding fluid restriction documentation |
| Social Services Director | Confirmed incomplete POST form for Resident #10 |
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