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
Census: 82
Deficiencies: 6
Date: Feb 10, 2025
Visit Reason
Routine inspection conducted to assess compliance with regulations related to resident dignity, accident hazards, medication administration, food safety, infection control, and overall facility operations.
Findings
The facility was found deficient in maintaining residents' dignity during dining, ensuring a safe environment free from accident hazards, preventing medication errors, maintaining food safety and sanitation standards, and implementing proper infection prevention and control practices.
Deficiencies (6)
Failure to maintain residents' dignity and respect during dining, including failure to knock before entering rooms and use of courtesy titles.
Unsecured sharps observed in a resident's room, posing accident hazards.
Medication error rate exceeded 5% due to crushing extended-release and enteric-coated medications.
Residents not free from significant medication errors related to crushing medications.
Food stored and served under unsanitary conditions; dishwasher not maintained at proper sanitizing temperatures; staff failed to perform hand hygiene during tray line service.
Failure to provide and implement an infection prevention and control program, including improper hand hygiene and reuse of alcohol wipes during medication administration.
Report Facts
Residents census: 82
Medication error rate: 6.06
Medication opportunities observed: 33
Medication errors observed: 2
Dishwasher rinse temperature: 151
Dishwasher rinse temperature: 144
Expired grape juice cups: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN L | Registered Nurse | Named in medication error findings related to crushing extended-release and enteric-coated medications |
| UM A | Unit Manager | Named in findings related to failure to knock and use courtesy titles during dining |
| CNA B | Certified Nursing Assistant | Named in findings related to failure to knock and use courtesy titles during dining |
| LPN J | Licensed Practical Nurse | Named in findings related to failure to knock and use courtesy titles during dining |
| CNA F | Certified Nursing Assistant | Named in findings related to failure to knock during dining |
| Staffing Coordinator E | Named in findings related to failure to knock during dining | |
| CNA G | Certified Nursing Assistant | Named in findings related to failure to knock during dining |
| RN K | Registered Nurse | Named in infection prevention findings related to improper hand hygiene and reuse of alcohol wipes |
| CNA I | Certified Nursing Assistant | Interviewed regarding Resident #47's razor use |
| CDM | Certified Dietary Manager | Named in food safety and sanitation findings |
| Regional RD | Regional Registered Dietitian | Named in food safety and sanitation findings |
| RD | Registered Dietitian | Named in food safety and sanitation findings |
Inspection Report
Deficiencies: 6
Date: Sep 18, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, respiratory care, infection control, and food handling practices.
Findings
The facility failed to complete timely Minimum Data Set (MDS) assessments for several residents following significant changes in condition, did not implement baseline care plans including respiratory interventions within 48 hours of admission for one resident, failed to update care plans to reflect changes, improperly stored nebulizer equipment increasing infection risk, failed to use hand sanitizer when delivering food trays, and used an ineffective disinfectant solution for Clostridium difficile isolation rooms.
Deficiencies (6)
Failed to complete timely Minimum Data Set (MDS) assessments within 14 days of significant change for 4 of 7 residents reviewed.
Failed to implement a baseline care plan including respiratory services within 48 hours of admission for 1 of 7 residents reviewed.
Failed to update a care plan to reflect removal of bedside commode for 1 of 41 residents reviewed.
Failed to properly store nebulizer mask in a plastic bag to prevent infection spread for 1 of 7 residents receiving respiratory services.
Failed to use hand sanitizer while delivering lunch trays to 2 rooms of 10 rooms observed.
Failed to use proper disinfectant solution effective against Clostridium difficile spores for cleaning isolation room floors.
Report Facts
Residents reviewed: 7
Residents reviewed: 41
Rooms observed: 10
Days late: 17
Oxygen flow rate: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed lack of respiratory interventions on baseline care plan and failure to update care plans | |
| RN #4 | Registered Nurse | Confirmed nebulizer mask was not stored in a bag |
| Registered Respiratory Therapist | Confirmed nebulizer equipment should be stored in a bag when not in use | |
| CNA #7 | Certified Nurse Aide | Observed failing to use hand sanitizer when delivering lunch trays |
| Housekeeper #1 | Used disinfectant germicidal spray not effective against C Diff spores for cleaning isolation rooms | |
| Director of Plant Operations | Unaware disinfectant spray used was ineffective against C Diff spores | |
| Administrator | Confirmed cleaning solution used was not effective on C Diff spores |
Inspection Report
Routine
Deficiencies: 2
Date: Sep 19, 2018
Visit Reason
The inspection was conducted to assess compliance with care plan implementation, infection prevention and control protocols, and respiratory equipment management in the nursing home.
Findings
The facility failed to follow care plan interventions for oxygen protocol for multiple residents, did not maintain infection control protocols including failure to use PPE when entering isolation rooms, and failed to ensure respiratory equipment tubing was changed and dated weekly as per policy. There was confusion between respiratory therapist and nursing staff regarding tubing change frequency.
Deficiencies (2)
Failed to follow care plan interventions for oxygen protocol for residents #39 and #76.
Failed to maintain infection control protocols including failure to use PPE when entering isolation rooms and failure to ensure respiratory equipment tubing was changed weekly and dated for residents #6, #39, #66, and #76.
Report Facts
Residents affected: 2
Residents affected: 4
Oxygen tubing change frequency: 7
Respiratory therapist visit frequency: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Confirmed facility policy for weekly respiratory equipment tubing changes and acknowledged failure to follow policy |
| CNA #2 | Certified Nurse Aide | Observed and confirmed oxygen tubing dated 9/5/18 in Resident #76's room |
| RN #1 | Registered Nurse | Interviewed regarding undated respiratory equipment in Resident #39's room |
| RT | Respiratory Therapist | Reported changing respiratory equipment tubing every 2 weeks and confirmed tubing change and dating protocols |
| LPN #1 | Licensed Practical Nurse | Confirmed confusion about tubing change order frequency and discontinuation |
| CNA #3 | Certified Nurse Aide | Observed entering isolation room without PPE during meal pass |
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