Deficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 11
Jan 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, accurate assessments, care planning, medication management, infection control, and other aspects of care.
Findings
The facility was found deficient in multiple areas including failure to protect resident dignity, inaccurate assessments, delayed and incomplete care planning, failure to follow physician orders for wound care, inaccurate weight monitoring, incomplete dialysis communication, unsecured medication cart, failure to implement enhanced barrier precautions, failure to offer hand hygiene during meal service, and failure to offer COVID-19 vaccinations according to current guidelines.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure resident's right to dignity was protected by posting a sign in the resident's room without consent. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately complete Minimum Data Set (MDS) assessments for falls and discharge location. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop a comprehensive care plan timely for pressure ulcers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise care plan to include new interventions after a fall. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician's orders for wound care were followed, including a 19-day gap in treatment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain accurate medical records, including documentation of wound treatments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident's weights were accurately recorded and monitored for weight loss. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure dialysis communication records were completed and available for review. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were secured appropriately on medication carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds and failed to offer hand hygiene during meal service. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to offer COVID-19 immunizations according to CDC recommendations and facility policy for eligible residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for dignity: 30
Residents reviewed for wounds: 4
Residents reviewed for falls: 3
Weight loss: 23
Weight loss percentage: 9.96
Residents reviewed for immunizations: 5
Medication carts observed: 2
Residents observed for meal service: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies including dignity, care planning, wound care, dialysis communication, medication cart security, infection control, and COVID-19 vaccination |
| Wound Care Nurse | Wound Care Nurse | Interviewed regarding wound care treatment gaps and documentation |
| LPN D | Licensed Practical Nurse | Named in wound care treatment and medication cart security deficiencies |
| RN I | Registered Nurse | Named in wound care treatment documentation deficiency |
| LPN C | Licensed Practical Nurse | Named in wound care treatment documentation deficiency |
| RN K | Registered Nurse | Named in dialysis communication process |
| CNA F | Certified Nursing Assistant | Observed and interviewed regarding failure to wear gown during linen change and hand hygiene assistance |
| LPN G | Licensed Practical Nurse | Observed and interviewed regarding medication cart security and failure to offer hand hygiene assistance |
| [NAME] H | Observed delivering meals and interviewed regarding failure to offer hand hygiene assistance |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 24, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of property involving Resident #84, who reported her wallet missing and unauthorized transactions on her bank accounts.
Findings
The facility failed to protect Resident #84 from wrongful use of her belongings and money. The investigation revealed that Housekeeper A was identified as the perpetrator through surveillance footage and was terminated. The facility reported the incident to Adult Protective Services, Ombudsman, state agency, and local law enforcement, and psychiatric services were consulted.
Complaint Details
The complaint was substantiated. Resident #84 reported her wallet missing and multiple unauthorized transactions on her bank accounts. The perpetrator was identified as Housekeeper A, who was terminated. The resident's financial institution reimbursed her for the lost money. The hearing for Housekeeper A was bound over to the grand jury and was awaiting trial.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to protect Resident #84 from misappropriation of property. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 16
Residents affected: 1
Estimated value of missing gift cards: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper A | Housekeeper | Identified as perpetrator of misappropriation and terminated for policy conduct violation |
| LPN B | Licensed Practical Nurse | Reported the missing wallet to the Assistant Director of Nursing and was involved in the investigation |
| Assistant Director of Nursing | Assistant Director of Nursing | Notified of the incident and involved in investigation |
| DON | Director of Nursing | Confirmed notification and investigation details |
| Administrator | Administrator | Notified of the incident and confirmed investigation details |
Inspection Report
Complaint Investigation
Deficiencies: 2
May 25, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow physician's orders and provide appropriate treatment for three residents, as well as concerns about nursing staff coverage.
Findings
The facility failed to follow physician orders for three residents by not obtaining ordered lab work and improperly administering pain medication. Additionally, the facility failed to provide the required minimum of 8 consecutive hours of registered nurse coverage on multiple days during the review period.
Complaint Details
The complaint investigation found substantiated failures including not following hospital discharge orders for lab work for Resident #65, not obtaining lab work for Resident #110 as ordered, and administering pain medication as needed instead of scheduled for Resident #112. Additionally, the facility did not meet RN staffing requirements for consecutive hours on multiple days.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow physician's orders and provide treatment for 3 residents, including failure to obtain ordered lab work and improper medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide registered nurse coverage for the minimum requirement of 8 consecutive hours a day for 7 days during the review period. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for physician orders: 9
Residents affected: 3
RN coverage days below 8 hours: 5
Days with no RN coverage: 2
Oxycodone administrations: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed failure to follow hospital discharge instructions and inability to find orders changing pain medication schedule |
| Registered Nurse #1 | Registered Nurse | Confirmed labs were not obtained and explained medication administration mix-up |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Confirmed failure to obtain labs and RN coverage issues |
| Medical Director | Medical Director | Confirmed expectation that hospital discharge orders be followed and that medication orders be followed as written |
| Pharmacist | Pharmacist | Confirmed admission orders for Oxycodone were written as scheduled |
| Advanced Nurse Practitioner | Advanced Nurse Practitioner | Stated expectation that lab work be ordered upon resident's return |
Inspection Report
Deficiencies: 1
May 22, 2019
Visit Reason
The inspection was conducted to assess compliance with mandatory annual Certified Nursing Assistant (CNA) in-service training requirements, specifically focusing on dementia care and abuse prevention education.
Findings
The facility failed to ensure that 4 of 7 CNAs reviewed completed the mandatory 12 hours of annual in-service training. Each of these CNAs received only 1.5 hours of training, which did not include the required dementia and abuse prevention content.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure mandatory annual 12 hours of CNA in-service training including dementia care and abuse prevention for 4 of 7 CNAs reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Certified Nursing Assistants reviewed: 7
CNAs not meeting training requirements: 4
Hours of in-service training received: 1.5
Mandatory annual training hours: 12
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