Inspection Reports for
Signal Mountain Senior Living

The complaint investigation revealed deficiencies including drug overdoses without proper care planning or response, multiple falls with inadequate follow-up care, failure to implement safety interventions, and inconsistent weight monitoring for a cognitively impaired resident with a PEG tube. Some incidents resulted in hospitalization and one resident death.

The facility was found to have multiple deficiencies including failure to properly manage residents with substance abuse histories, inadequate response to medical emergencies, failure to implement safety interventions for high fall risk residents, and inconsistent nutritional monitoring. These deficiencies were deemed detrimental to resident health and safety.

The facility failed to evacuate eleven of sixty-nine residents within thirteen minutes during a fire drill, with eight residents refusing to participate and three not evacuating in time. The facility also failed to conduct required fire drills during sleeping hours and did not update care plans for two residents after significant condition changes.

A Licensed Practical Nurse administered medication intended for one resident to another, causing adverse reactions. The facility was found not in substantial compliance with Tennessee Rules and Regulations regarding medication administration.

The facility was placed on probation due to deficiencies including medication administration, fire safety evacuation, and failure to conduct proper fire drills. The Order outlines corrective actions such as staff training, fire drill documentation, management changes, and payment of civil monetary penalties totaling $29,000. The Board found that the facility complied with the October 2019 Agreed Order and lifted the probation.

The facility was found to have multiple deficiencies including failure to ensure all medications were administered properly, failure to follow up on missed medications, and failure to assess and manage fall risks for residents. These violations led to disciplinary action and civil monetary penalties.

The complaint survey was conducted from August 5 to August 12, 2019. Surveyors substantiated multiple deficiencies related to medication administration, resident care, staffing, sanitation, resident transfers, and fire safety. The Commissioner suspended admissions and imposed civil monetary penalties based on these findings.

Surveyors found multiple deficiencies including failure to administer medications properly, inadequate assistance with activities of daily living, insufficient staffing, failure to maintain a sanitary environment, failure to discharge residents requiring higher care, and failure to conduct proper fire drills. The facility was also cited for failure to provide proper resident care and documentation.

The complaint survey conducted on April 18, 2018, was substantiated by findings of serious violations including unlicensed medication administration and failure to update resident care plans.

The survey found that the facility failed to update care plans to include hospice care and emergency evacuation plans for residents, and unlicensed medication technicians administered medications. These violations constituted grounds for disciplinary action.

The complaint investigation was substantiated based on findings that Resident #3 eloped and was found injured outside the facility, and Resident #2 eloped through a secure unit door. The facility admitted failure to provide daily awareness and a secure environment for these residents.

The surveyors found serious violations of state laws and regulations resulting in endangerment to the health, safety, and welfare of residents. Specifically, two residents eloped from the facility, and the facility failed to provide daily awareness of their whereabouts and a secure environment.