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
Annual Inspection
Deficiencies: 4
Date: Dec 1, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, including quarterly, discharge, and accuracy of Minimum Data Set (MDS) assessments, as well as care related to indwelling urinary catheters.
Findings
The facility failed to complete quarterly and discharge assessments within required timeframes for multiple residents and failed to accurately assess residents for use of urinary catheters and antipsychotic medications. Additionally, the facility failed to provide appropriate catheter care and maintain physician orders for indwelling catheters for some residents.
Deficiencies (4)
Failed to complete quarterly assessments within regulatory time frames for 5 of 42 sampled residents.
Failed to complete discharge assessments within regulatory time frames for 16 of 42 sampled residents.
Failed to accurately assess residents for use of urinary catheters and antipsychotic medications for 2 of 21 sampled residents.
Failed to provide appropriate care and services to maintain indwelling urinary catheters for 2 of 2 sampled residents.
Report Facts
Residents with untimely quarterly assessments: 5
Residents with untimely discharge assessments: 16
Residents with inaccurate assessments: 2
Residents with inadequate catheter care: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator #1 | Confirmed quarterly assessments were not completed timely and confirmed Resident #280 should have been coded for an indwelling catheter. | |
| MDS Coordinator #2 | Confirmed quarterly assessments were not completed timely and confirmed Resident #382 was coded incorrectly for antipsychotic medications. | |
| MDS Coordinator #3 | Confirmed quarterly assessments were not completed timely. | |
| Certified Nursing Assistant (CNA) #2 | Certified Nursing Assistant | Observed providing catheter care without proper hand hygiene and confirmed hand hygiene should be performed between glove changes. |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Observed providing catheter care improperly and confirmed proper catheter cleaning procedures. |
| Unit Manager | Confirmed proper catheter care procedures and hand hygiene expectations. | |
| Director of Nursing | Director of Nursing | Confirmed no physician orders existed for Resident #280's indwelling catheter. |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed no physician orders existed for Resident #280's indwelling catheter. |
Inspection Report
Deficiencies: 0
Date: Oct 22, 2019
Visit Reason
The document is a statement of deficiencies and plan of correction for Signature Healthcare of Primacy, summarizing the results of a survey completed on 2019-10-22.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Deficiencies: 6
Date: Dec 19, 2018
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration, pressure ulcer care, medication error rates, medication storage, and infection prevention and control practices at the nursing facility.
Findings
The facility was found deficient in multiple areas including improper medication administration through enteral tubes and eye drops, failure to follow physician orders for pressure ulcer care, medication errors exceeding 5%, improper medication storage and labeling, and inadequate infection prevention practices such as hand hygiene and equipment cleaning.
Deficiencies (6)
Failure to follow facility policy for administration of medications through an enteral tube and administration of eye drops.
Failure to follow physician orders for treatment of pressure ulcers for one resident.
Medication error rate exceeded 5 percent with 3 errors observed out of 26 opportunities.
Failure to ensure residents were free from significant medication errors when one nurse did not administer correct dosage.
Medications were left unattended and out of sight, and medications with shortened expiration dates were not dated when opened.
Failure to ensure infection prevention practices including hand hygiene, use of barriers, and cleaning of reusable equipment during medication administration.
Report Facts
Medication error rate: 11.538
Medication errors observed: 3
Medication administration opportunities observed: 26
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Failed to follow medication administration policy for enteral tube and eye drops; failed infection control practices |
| RN #1 | Registered Nurse | Failed to follow medication administration policy for enteral tube and eye drops; involved in medication errors |
| LPN #2 | Licensed Practical Nurse | Left medications unattended and out of sight during administration |
| LPN #3 | Licensed Practical Nurse | Involved in medication errors and failed to administer correct medication dosage; failed infection control practices |
| LPN #4 | Licensed Practical Nurse | Confirmed resident not wearing bilateral heel boots as ordered |
| Director of Nursing | Director of Nursing (DON) | Interviewed multiple times regarding proper medication administration, infection control, and compliance with physician orders |
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