Deficiencies (last 5 years)
Deficiencies (over 5 years)
13.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
205% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
40
30
20
10
0
Inspection Report
Enforcement
Deficiencies: 14
Date: Jun 16, 2025
Visit Reason
A complaint and revisit survey were conducted from March 10, 2025, through March 26, 2025, resulting in deficiencies affecting resident health, safety, and welfare. A subsequent monitoring visit occurred on June 16, 2025, as part of a Suspension of Admissions procedure.
Complaint Details
The visit was complaint-related, triggered by allegations of deficiencies affecting resident health, safety, and welfare. The complaint was substantiated as evidenced by multiple cited violations and findings.
Findings
The facility was cited for multiple serious deficiencies including failure to provide proper staffing and protective care, allowing resident elopements, falls resulting in death, impaired nurse on duty, medication administration failures, unsecured medications, failure to submit acceptable plans of correction, and failure to investigate resident abuse videos. The licensee voluntarily surrendered the facility license and admissions were suspended.
Deficiencies (14)
Respondent failed to provide proper staffing causing residents to suffer pain without timely medication administration during night shifts.
Respondent failed to provide protective care, allowing multiple residents to elope without staff knowledge or supervision.
Respondent failed to implement interventions to prevent further elopements and failed to monitor residents after elopement incidents.
Respondent failed to prevent falls resulting in injury and death, and failed to revise care plans or implement interventions to prevent falls.
Respondent's sole nurse on duty was impaired, unable to properly administer medications, and possessed alcohol on premises.
Respondent failed to submit an acceptable Plan of Correction within the statutory timeframe and was re-cited for all deficiencies from the initial survey.
Respondent failed to perform required criminal background checks and registry checks for employees as mandated by law.
Respondent failed to have a licensed nurse available to assess and manage pain for residents, repeating prior violations.
Respondent failed to provide documentation of licensed nursing staff during night-time hours during revisit survey.
Respondent failed to maintain hospice logs, medical records, and quality measure documents for hospice residents, repeating prior violations.
Respondent failed to ensure timely and proper medication administration and failed to notify physicians of late or missed doses.
Respondent failed to secure medications properly, storing controlled substances under a single lock and leaving unsecured bottles accessible.
Respondent failed to report and investigate emotional abuse and exploitation of residents documented on videos made by facility employees.
Respondent employed a Director of Nursing without verifying license status, criminal conviction, or registry status as required.
Report Facts
Residents affected by pain medication failure: 3
Residents who eloped: 4
Residents who suffered falls: 3
Residents for whom medication administration records were missing: 28
Dates of initial complaint and revisit survey: March 10, 2025 through March 26, 2025
Date of monitoring visit: June 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Sole nurse on duty | Observed impaired, had difficulty opening narcotics drawer, slurred speech, possessed alcohol, and failed medication administration. |
| Activities Director | Activities Director (AD) | Confirmed smelling alcohol on LPN #1's breath and noted problematic behavior. |
| Director of Nursing | Director of Nursing (DON) | Not licensed in Tennessee, license revoked in 1995, employed without verifying license or criminal status. |
| Maintenance and Safety Director | Maintenance and Safety Director (MSD) | Admitted receiving medication bottle without keys to secure medication cart. |
| Administrator | Facility Administrator | Admitted absence during monitoring visit and failure to act on videos of resident abuse. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 26, 2025
Visit Reason
A complaint and revisit survey were conducted to investigate violations of licensure statutes and regulations affecting the health, safety, and welfare of residents at Royal Retreat Assisted Care Living Facility.
Complaint Details
The visit was complaint-related and substantiated, with deficiencies cited that affect the health, safety, and welfare of residents, including failure to provide proper staffing, failure to prevent elopements and falls, and failure to maintain updated care plans.
Findings
The facility was cited for multiple deficiencies including failure to provide proper staffing and nursing coverage during night shifts, failure to prevent resident elopements, inadequate fall prevention interventions, and failure to conduct timely care plan meetings and revise plans of care as residents' needs changed.
Deficiencies (4)
Tenn. Comp. R. & Regs. 0720-26-.06(1)(a)(4) [Administration]: The facility failed to have a licensed nurse available as needed, resulting in residents suffering pain without timely medication.
Tenn. Comp. R. & Regs. 0720-26-.07(7)(a)(1) [Services Provided]: The facility failed to provide protective care, allowing multiple residents to elope without staff knowledge and without implementing interventions.
Tenn. Comp. R. & Regs. 0720-26-.07(7)(a)(2) [Services Provided]: The facility failed to provide safety when in the ACLF, with residents suffering falls and no interventions implemented to prevent further incidents.
Tenn. Comp. R. & Regs. 0720-26-.12(5)(a) [Resident Records]: The facility failed to conduct care plan meetings and review or revise plans of care as residents' needs changed to prevent elopement and falls.
Report Facts
Type A Civil Monetary Penalties: 4
Civil Monetary Penalty amount: 3000
Civil Monetary Penalty amount: 3000
Civil Monetary Penalty amount: 3000
Civil Monetary Penalty amount: 3000
Total Civil Monetary Penalties: 12000
Monitor hours per week: 20
Inspection Report
Life Safety
Deficiencies: 1
Date: May 16, 2024
Visit Reason
The visit was a Life Safety Complaint Survey conducted by Commission surveyors at Royal Retreat Assisted Care Living Facility on or about May 16, 2024.
Complaint Details
This was a complaint investigation triggered by a Life Safety Complaint survey. The complaint was substantiated by findings of failure to conduct required fire drills.
Findings
The facility failed to conduct required quarterly fire drills for all shifts during 2023 and the first quarter of 2024, including drills during sleeping hours. The last documented fire drill was in December 2022.
Deficiencies (1)
The facility failed to conduct quarterly fire drills for all shifts during 2023 and the first quarter of 2024 as required. There was no documentation of fire drills and drills during sleeping hours were not conducted.
Report Facts
Civil Monetary Penalty: 3000
Civil Monetary Penalty: 3000
Total Civil Monetary Penalty: 6000
Days for Payment: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Manivannan Sivalingam | Administrator | Admitted there was no documentation of fire drills and drills had not been conducted as required |
Inspection Report
Enforcement
Deficiencies: 0
Date: Oct 7, 2020
Visit Reason
This document is a Consent Order related to enforcement action by the Tennessee Board for Licensing Health Care Facilities against Legacy Assisted Living and Memory Care following multiple surveys and deficiencies, including complaint investigations and revisits from 2017 through 2020.
Findings
The facility had serious deficiencies affecting resident health, safety, and welfare, resulting in suspension of admissions and probation. Despite plans of correction and agreements, deficiencies persisted leading to license suspension and eventual transfer of residents and facility closure.
Report Facts
Deficiencies cited: 3
Plan of Correction timeframe: 14
Probation period: 1
Days notice of discharge: 30
Management company onsite days: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paul Valentine | Receiver | Authorized representative overseeing management company and compliance |
| Caroline R. Tippens | Senior Associate General Counsel | Signed consent order on behalf of Tennessee Department of Health |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 3, 2020
Visit Reason
Surveyors conducted a complaint survey on March 3, 2020, triggered by complaints about serious deficiencies at Legacy Assisted Living and Memory Care.
Complaint Details
Surveyors substantiated three complaints during the investigation. Resident #1 exhibited aggressive behavior and was a threat to others. The facility failed to investigate an assault on Resident #1. Resident #3 was not provided appropriate care for dysphagia, leading to emergency interventions.
Findings
The facility was found to have serious deficiencies including allowing a physically and verbally aggressive resident to remain despite threats to others, failure to investigate an assault allegation, and failure to provide appropriate care to a resident with severe dysphagia, resulting in actual harm.
Deficiencies (3)
The facility allowed Resident #1, who exhibited physical and verbal aggression, to remain despite posing a threat to herself and others. The facility failed to investigate an assault allegation involving Resident #1.
The facility failed to provide appropriate care to Resident #3 with severe dysphagia, including not following physician orders for pureed food, resulting in two emergency room visits and an endoscopic removal of an apple slice from her throat.
The facility's deficient practices resulted in actual harm to Residents #1 and #3 due to failure to follow physician orders and provide safety.
Report Facts
Complaints substantiated: 3
Resident age: 77
Resident age: 80
Inspection Report
Deficiencies: 4
Date: Dec 12, 2019
Visit Reason
The document is a Consent Order related to regulatory disciplinary action involving Legacy Assisted Living and Memory Care at Lenox Park following multiple surveys, revisits, complaint investigations, and enforcement actions over 2017-2019.
Complaint Details
The complaint investigation substantiated that the facility failed to investigate multiple allegations against licensed practical nurses and failed to provide documentation of these investigations.
Findings
The facility had multiple deficiencies including failure to revise residents' care plans, failure to investigate allegations against staff, failure to provide adequate documentation, medication administration issues, and safety concerns such as bruises and falls among residents. The facility was placed on probation and suspension of admissions until deficiencies were corrected.
Deficiencies (4)
The facility failed to revise Resident #1's care plan with new interventions to promote safety or prevent falls despite multiple incidents of bruising and falls. The facility also failed to document investigations of allegations against licensed practical nurses and failed to provide documentation of care plan revisions for Resident #2's aggressive behaviors.
The facility failed to notify Resident #1's physician or update the care plan after incidents including falls, vomiting, and infections. There was no documentation that ordered treatments such as antibiotics and insulin were administered or that x-rays were performed.
Resident #1's controlled medications, including Lorazepam, were not properly disposed of. Multiple hazardous items such as razors and bleach were found within reach of residents in the memory care unit.
The facility failed to provide documentation of safety education for staff after Resident #3's injury and failed to revise Resident #4's care plan to address pressure sores or preventative interventions.
Report Facts
Deficiencies cited: 3
Sutures: 3
Days: 30
Dates: 2019
Inspection Report
Enforcement
Deficiencies: 4
Date: Sep 11, 2019
Visit Reason
The inspection was conducted as part of health and life safety surveys at Legacy Assisted Living & Memory Care at Lenox Park, following prior probation and ongoing regulatory oversight.
Findings
The surveys revealed serious deficiencies affecting the health, safety, and welfare of residents, including failure to update care plans, inadequate fall prevention, failure to prohibit portable space heaters, and failure to conduct required fire and disaster drills.
Deficiencies (4)
Rule 1200-08-25-.12(5)(a) [RESIDENT RECORDS]: The facility failed to develop and revise plans of care for residents in a timely manner to ensure safety and prevent falls and dehydration.
Rule 1200-08-25-.10(2)(h) [LIFE SAFETY]: The facility failed to prohibit open flames and portable space heaters, as evidenced by a portable space heater found in the activities director's storage room.
Rule 1200-08-25-.10(3) [LIFE SAFETY]: The facility failed to conduct required fire drills quarterly for each work shift in each building.
Rule 1200-08-25-.16(2) [DISASTER PREPAREDNESS]: The facility failed to maintain documentation and training logs for disaster preparedness drills including severe weather and bomb threat scenarios.
Report Facts
Civil monetary penalties: 15000
Probation period: 1
Suspension effective date: Suspension of admissions effective October 2, 2019.
Revisit survey cost cap: 30000
Days to transfer residents: 30
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 10, 2019
Visit Reason
The visit was a follow-up survey conducted on April 10, 2019, to determine if previously identified deficient practices and conditions detrimental to resident health, safety, or welfare had been corrected as stated in the facility's approved plan of correction.
Findings
The surveyor determined that the deficient practices and conditions had been corrected and the facility returned to substantial compliance for state licensing purposes. Consequently, the Board of Licensing ordered the lifting of the suspension of admission of new residents.
Inspection Report
Complaint Investigation
Deficiencies: 17
Date: Nov 26, 2018
Visit Reason
Surveyors conducted a complaint survey from November 26, 2018 through December 6, 2018 to investigate deficiencies cited in the September 2018 revisit survey and to investigate six new complaints.
Complaint Details
The complaint investigation was conducted from November 26, 2018 through December 6, 2018. Deficiencies from the September 2018 revisit survey were recited and new deficiencies were identified during the complaint investigation.
Findings
The facility had multiple serious deficiencies affecting the health, safety, and welfare of residents, including failure to follow medication orders, insufficient staffing to meet resident needs, failure to prevent falls, and failure to maintain proper documentation and care plans. The facility was under probation and suspension of admissions due to these deficiencies.
Deficiencies (17)
The facility failed to follow their thirty (30) day termination discharge policy procedure for Resident #1.
The facility failed to obtain physician's orders for supplemental oxygen use and continuous positive airway pressure device use for Residents #1 and #2.
The facility failed to maintain a medical record that included time and circumstances of discharge and conditions for discharge of Resident #1.
Medication administration records revealed Resident #2's blood pressure medication was withheld for seven and nine days without documentation of a physician's order.
Resident #2 was observed lying on a soiled incontinent pad and smelling strongly of urine.
Resident #3 had medications not administered as ordered with no documentation explaining the omissions.
Resident #3 was observed wearing stained clothing and having foul body odor.
The facility failed to ensure sufficient staff to meet the needs of Resident #3's plan of care.
Resident #5 was found on the floor multiple times without wearing a call pendant and interventions to prevent falls were not consistently followed.
Resident #6 was not observed wearing a call pendant and staff misappropriated Resident #6's debit card without reporting the incident to the Department of Health.
Resident #9 was not receiving medications as ordered with no documentation explaining the omissions.
The facility failed to provide sufficient nursing staff to ensure medications were administered to Residents #2, #3, and #9 as ordered.
The facility failed to ensure sufficient staff to prevent falls for Residents #4, #5, #6, and #7.
Strong urine odors were observed in rooms belonging to Residents #3, #4, #5, #6, #8, and #9.
The Director of Nursing confirmed staff were storing residents' wet soiled clothing in their rooms.
The facility failed to ensure staff met all activities of daily living for Residents #3, #4, #5, #6, #8, and #9.
The facility failed to ensure sufficient staff to maintain clean linens for Residents #2 and #8.
Report Facts
Civil monetary penalties: 4500
Deficiency count: 30
Deficiency count: 14
Deficiency count: 3
Plan of Correction submission date: 2019
Probation period: 10
Suspension effective date: 2018
Rent owed by Resident #6: 4244.52
Assessment cost: 30000
Inspection Report
Enforcement
Deficiencies: 3
Date: Sep 13, 2018
Visit Reason
The document is a Consent Order resulting from a complaint survey conducted from November 1, 2017 through December 4, 2017, which revealed serious deficiencies affecting the health, safety, and welfare of residents at Legacy Assisted Living and Memory Care. The Consent Order addresses the facility's failure to correct deficiencies and outlines terms for probation and corrective actions.
Complaint Details
The visit was complaint-related, triggered by a complaint survey conducted from November 1, 2017 through December 4, 2017. The survey revealed serious deficiencies affecting resident health, safety, and welfare. The facility was found to have ongoing issues despite prior corrective efforts.
Findings
The facility had serious deficiencies related to resident care, including failure to provide medical services, protective care, monitoring, wound care, and proper plan of care revisions. Despite improvements and reduction in deficiencies, the facility remained under suspension of admissions due to ongoing concerns. The Board imposed civil monetary penalties and extended probation with required corrective actions.
Deficiencies (3)
The facility failed to ensure Resident #11 received medical services from a licensed provider.
The facility failed to provide Residents #1, #2, and #11 with protective care, failed to monitor changes in health status, provide appropriate wound care, and ensure physicians' orders for medication administration.
The facility failed to develop and revise the plan of care for Residents #1, #2, and #11 to ensure all resident needs were met.
Report Facts
Civil monetary penalties: 4500
Deficiency counts: 30
Deficiency counts: 14
Deficiency counts: 3
Deficiency counts: 1
Probation period: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shelley Morgan | Consultant | Consultant to Legacy Assisted Living who resigned due to health concerns in September 2018. |
| Cedric Davis | Administrator | Named as Respondent in the Consent Order. |
Inspection Report
Enforcement
Deficiencies: 0
Date: May 22, 2018
Visit Reason
A revisit survey and investigation were conducted on May 22-23, 2018, at Legacy Assisted Living and Memory Care to assess compliance with licensure statutes and regulations following prior probation status.
Findings
The Board found serious deficiencies detrimental to the health, safety, and welfare of residents, including violations related to staffing, medications, protective care, admissions, life safety, and resident records. As a result, the Board exercised its authority to suspend admissions effective June 6, 2018.
Report Facts
Probation period: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rene Saunders | M.D., Chair, Board of Licensing for Health Care Facilities | Signed the enforcement order and suspension notice |
Inspection Report
Complaint Investigation
Deficiencies: 17
Date: Feb 12, 2018
Visit Reason
The visit was conducted as a complaint survey at Legacy Assisted Living and Memory Care at Lenox Park between November 1, 2017 and December 4, 2017, with an abbreviated survey on February 12, 2018, related to multiple complaints and allegations regarding resident care and facility compliance.
Complaint Details
The survey was complaint-related, triggered by multiple allegations concerning resident care, medication administration, falls, dehydration, and facility safety. Eight of the complaints were substantiated with deficiencies cited.
Findings
The survey found multiple deficiencies including inadequate documentation of resident monitoring, medication administration, care plans, and staff interventions. Issues with resident falls, dehydration, medication disposal, fire safety, and dietary services were also identified. Some deficiencies from a prior December 2017 survey were re-cited during the revisit.
Deficiencies (17)
Resident #1 was unresponsive upon arrival and the facility failed to monitor her condition adequately. Medication administration documentation for Resident #1 was incomplete from August 19-31, 2017.
Resident #1 was not eating or walking well in October 2017, and the facility lacked adequate documentation of assessment and monitoring. Physician notes were not provided to the facility.
Resident #2 had multiple falls and the facility failed to document interventions or update the plan of care to prevent further falls or address changes in status.
Resident #3's medication administration was not documented in accordance with physician orders, and no plan of care was developed during the stay.
Residents #4, 5, 7, 8, 9, 10, 11, 12, and 13 had falls or dehydration with inadequate staff interventions documented to prevent injury or dehydration.
Resident #5 experienced allergic reaction and pain with insufficient follow-up assessments and documentation of physician notification.
Resident #8 had multiple unexplained injuries and the facility failed to assess or document interventions or revise the plan of care.
Resident #9 displayed threatening and violent behavior with no documented plan of care to protect the resident or others.
Resident #10's plan of care was not developed or revised following two falls.
Resident #11 had multiple falls with no documented staff interventions to prevent further injury.
Resident #12 had constipation and unwell episodes with no documented staff interventions or physician orders for additional medication doses.
Resident #13 was started on multiple medications without documentation of monitoring or reasons for initiation, and the facility failed to develop or revise the plan of care.
The facility failed to develop and implement an effective performance improvement plan for falls, injuries, dehydration, narcotics diversion, and resident behaviors for January and February 2018.
There were no call lights in residents' rooms and the facility lacked a list of residents with functioning call pendants. LifeStation call pendants were purchased but not yet operational.
The facility failed to follow the planned menu for February 20, 2018, and lacked a therapeutic diet manual signed by a dietitian until after the survey.
The medication disposal policy did not address disposal of scheduled narcotic medications, but a new policy and secure disposal process were implemented after the survey.
Fire drills were not documented for 2017 at the time of the survey, sprinklers were misaligned or missing in several areas, and frozen sprinkler lines caused problems. These issues were corrected after the survey.
Report Facts
Civil monetary penalties: 4500
Survey dates: Feb 12, 2018
Survey period: Nov 1, 2017
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