Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% better than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 4
Oct 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, food safety, and medical record accuracy at Nhc Healthcare, Chattanooga.
Findings
The facility failed to accurately code PASRR level 2 outcomes for three residents, did not implement a fall intervention program (L.A.M.P) for one resident, served a coffee cup that was not properly cleaned, and had incomplete and inaccurate medical records for one resident regarding blood glucose monitoring.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to accurately code a PASRR level 2 on the Minimum Data Set (MDS) assessment for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement a person centered comprehensive care plan intervention related to falls for 1 resident; L.A.M.P program signage was not used as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure 1 coffee cup was clean prior to resident use of 5 coffee cups observed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the medical record was accurate and complete for 1 resident regarding blood glucose monitoring and hyperglycemic protocol. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for PASRR: 7
Residents affected by PASRR coding deficiency: 3
Residents reviewed for falls: 3
Residents affected by falls care plan deficiency: 1
Coffee cups observed: 5
Coffee cups unclean: 1
Residents reviewed for blood glucose monitoring: 5
Residents affected by medical record deficiency: 1
Blood sugar reading: 434
Blood sugar reading: 264
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN F | Licensed Practical Nurse | Interviewed regarding L.A.M.P program signage and fall intervention for Resident #51 |
| CNA G | Certified Nursing Assistant | Interviewed regarding L.A.M.P program signage and fall intervention for Resident #51 |
| Care Plan Coordinator H | Care Plan Coordinator | Confirmed L.A.M.P program signage was not implemented for Resident #51 |
| Director of Nursing | Director of Nursing | Confirmed coffee cup was not properly cleaned and medical record deficiencies for Resident #117 |
| Administrator | Administrator | Stated dietary staff were expected to inspect dishes, cups, and utensils for cleanliness |
| Nurse Practitioner D | Nurse Practitioner | Interviewed regarding insulin orders and blood sugar management for Resident #117 |
| Medical Doctor E | Medical Doctor | Reviewed Resident #117's blood sugars and commented on elevated blood sugar |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed medical record for Resident #117 was incomplete and inaccurate |
Inspection Report
Annual Inspection
Deficiencies: 6
Jan 10, 2022
Visit Reason
The inspection was conducted as part of a routine annual survey to assess compliance with regulatory requirements for nursing home care, including resident dignity, accurate assessments, care planning, range of motion services, accident prevention, and food safety.
Findings
The facility was found deficient in multiple areas including failure to protect resident dignity by posting unauthorized medical signage in resident rooms, inaccurate Minimum Data Set (MDS) assessments for several residents, incomplete and non-individualized care plans, failure to provide recommended range of motion services, inadequate fall prevention interventions, and unsanitary kitchen conditions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Posting medical information signage above residents' beds without resident or family request, visible to residents, staff, and visitors, violating patient dignity policy. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to accurately complete Minimum Data Set (MDS) assessments for residents, including missing documentation of limb prosthesis, pressure ulcers, and discharge status. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement comprehensive, individualized care plans addressing all resident needs including pressure ulcers and prosthetic devices. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate range of motion (ROM) services as recommended by physical therapy for a resident with limited mobility. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement new fall prevention interventions after a resident fall, despite policy requiring new interventions to keep patient safe. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain a clean kitchen environment, including dried food debris on equipment and oil spills on the floor during food preparation. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 34
Residents affected: 4
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents in facility: 174
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| PT #1 | Physical Therapist | Provided recommendations for range of motion services for Resident #41 |
| Director of Nursing | Confirmed policy expectations and deficiencies related to signage, care plans, and ROM documentation | |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding awareness and completion of ROM for Resident #41 |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding completion of ROM for Resident #41 |
| Registered Nurse #1 | Registered Nurse | Responsible for overseeing falls; did not implement new fall intervention for Resident #43 |
| Dietary Supervisor | Observed cleaning kitchen equipment improperly during food preparation | |
| Certified Dietary Manager | Certified Dietary Manager | Responsible for kitchen oversight; stated equipment should be cleaned after each use |
Inspection Report
Deficiencies: 0
Mar 13, 2019
Visit Reason
The document is a statement of deficiencies and plan of correction for Nhc Healthcare, Chattanooga, related to a survey completed on 2019-03-13.
Findings
No health deficiencies were found during the survey.
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