Deficiencies (last 4 years)
Deficiencies (over 4 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
104 residents
Based on a July 2024 inspection.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jul 11, 2024
Visit Reason
The inspection was conducted to review the facility's compliance with timely completion and transmission of resident assessments using the Centers for Medicare & Medicaid Services-specific Resident Assessment Instrument (RAI) process.
Findings
The facility failed to complete resident assessments within the regulatory time frames for 7 of 28 sampled residents. The assessments were completed and transmitted late, as confirmed by the MDS Coordinator and Administrator during interviews.
Deficiencies (1)
Failure to complete resident assessments using the CMS-specific RAI process within regulatory time frames for 7 of 28 sampled residents.
Report Facts
Residents sampled: 28
Residents affected: 7
Assessment completion delays: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Confirmed assessments were completed and transmitted late | |
| Director of Nursing (DON) | Responsible for ensuring timely completion of MDS resident assessments | |
| Administrator | Confirmed responsibility for ensuring timely completion of assessments |
Inspection Report
Census: 104
Deficiencies: 6
Date: Jul 11, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including maintenance of a safe environment, timely completion of resident assessments, care planning, feeding tube care, infection control, and staff training.
Findings
The facility was found deficient in multiple areas including failure to maintain safe bathroom flooring, incomplete and untimely resident assessments, lack of documented care plan meetings, improper feeding tube care, inadequate infection control practices, and failure to provide mandatory annual in-service training for certified nursing assistants.
Deficiencies (6)
Failed to provide effective maintenance services to ensure a safe, functional, and comfortable environment as evidenced by disrepair of bathroom flooring in 1 of 104 occupied resident rooms.
Failed to complete resident assessments within regulatory time frames for 7 of 28 sampled residents.
Failed to ensure care plan meetings were scheduled and documented for 2 of 2 residents reviewed.
Failed to follow practitioner orders for PEG tube feeding and failed to date and label PEG tube feedings for 1 of 2 residents reviewed for enteral feedings.
Failed to ensure proper infection control practices for 1 of 2 residents reviewed for isolation precaution.
Failed to ensure mandatory annual 12 hours of in-service training for 12 of 61 certified nursing assistants reviewed.
Report Facts
Residents affected: 1
Residents affected: 7
Residents affected: 2
Residents affected: 1
Residents affected: 1
Census: 107
Staff affected: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN N | Licensed Practical Nurse | Noted bathroom floor as a fall risk and would notify maintenance |
| CNA M | Certified Nursing Assistant | Noticed bathroom flooring issues for over a year |
| Maintenance Director | Aware of bathroom flooring issue for over a year, planned to order replacement flooring | |
| Administrator | Confirmed repairs should be addressed immediately and not take a year | |
| MDS Coordinator | Confirmed late completion of resident assessments and responsibility of Director of Nursing | |
| Director of Nursing | DON | Responsible for ensuring timely MDS assessments and care plan meetings |
| LPN O | Licensed Practical Nurse | Administered PEG tube medications but failed to check placement and clean syringe properly |
| LPN Q | Licensed Practical Nurse | Failed to flush PEG tube between medications and improperly administered medications |
| LPN R | Licensed Practical Nurse | Confirmed resident was not in contact isolation despite orders |
| Human Resources Director | Confirmed lack of documentation for CNA in-service training |
Inspection Report
Routine
Deficiencies: 1
Date: May 5, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan development and revision requirements, specifically focusing on the failure to revise and update care plans to include fall interventions and communicate fall risk to staff for multiple residents.
Findings
The facility failed to revise and update care plans to include fall interventions and communicate fall risk to staff for 7 of 8 sampled residents with documented falls. Multiple residents had documented falls and related injuries, but their care plans lacked documentation of these events and corresponding interventions. Staff interviews confirmed lack of communication and documentation regarding fall risks and interventions.
Deficiencies (1)
Failure to revise and update the Care Plan to include fall interventions and communicate to staff the residents with a fall risk for 7 of 8 sampled residents reviewed with falls.
Report Facts
Fall Risk Assessment Scores: 14
Fall Risk Assessment Scores: 13
Fall Risk Assessment Scores: 15
Fall Risk Assessment Scores: 13
Fall Risk Assessment Scores: 14
Fall Risk Assessment Scores: 16
Fall Risk Assessment Scores: 18
BIMS Scores: 10
BIMS Scores: 6
BIMS Scores: 3
BIMS Scores: 15
BIMS Scores: 13
BIMS Scores: 8
BIMS Scores: 8
Fall Dates: 2
Fall Dates: 5
Fall Dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Incorrectly placed Resident #1's orthopedic boot |
| CNO | Chief Nursing Officer | Correctly placed Resident #1's orthopedic boot after RN #1 error |
| LPN Unit Manager #1 | Licensed Practical Nurse Unit Manager | Acknowledged need for in-service on splint application |
| CNA #1 | Certified Nursing Assistant | Reported lack of written communication about fall risk and interventions |
| CNA #2 | Certified Nursing Assistant | Reported lack of written communication about fall risk and interventions |
| RN #2 | Registered Nurse | Reported no list of fall risk residents and lack of documentation |
| Unit Manager LPN #2 | Licensed Practical Nurse Unit Manager | Confirmed no documentation of fall interventions for multiple residents |
| Unit Manager LPN #1 | Licensed Practical Nurse Unit Manager | Discussed communication issues regarding fall risk |
| Administrator | Facility Administrator | Acknowledged multiple issues and lack of awareness until inspection visit |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 26, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure adequate supervision to prevent elopement of a resident with severe cognitive impairment.
Complaint Details
The complaint investigation found that Resident #5, who had severe cognitive impairment, exited the facility unsupervised when a visitor entered and held the door open. The resident was outside for approximately 58 minutes before being found by staff. The facility was cited Immediate Jeopardy from 2/13/2023 through 2/20/2023. The Immediate Jeopardy was removed after corrective actions were implemented and validated onsite.
Findings
The facility failed to provide adequate supervision to prevent elopement for Resident #5, who exited the facility unsupervised and was outside for approximately 58 minutes. This failure resulted in Immediate Jeopardy to resident health or safety, which was removed after corrective actions were implemented and validated onsite.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, specifically elopement of Resident #5.
Report Facts
Duration resident was unsupervised outside: 58
Date Immediate Jeopardy existed from: 2023-02-13 to 2023-02-20
Date survey completed: Apr 26, 2023
Temperature: 66
In-service training completion date: Feb 20, 2023
Door lock schedule: 7:30 PM to 6:30 AM
Frequency of door code change: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #2 | Nurse Practitioner | Confirmed Resident #5 was severely cognitively impaired and it was not safe for her to be outside unsupervised. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Wrote nurse's note documenting Resident #5 found sitting on front porch after elopement. |
| Administrator | Administrator | Interviewed and confirmed it was not safe for Resident #5 to be outside unsupervised; involved in corrective action validation. |
| Patient Care Liaison #1 | Patient Care Liaison | Observed Resident #5 sitting outside and asleep on the porch. |
| Former Business Office Manager | Business Office Manager | Provided interview details about Resident #5 sitting outside on the patio. |
Inspection Report
Census: 109
Deficiencies: 9
Date: Jul 25, 2022
Visit Reason
The inspection was conducted to investigate multiple compliance issues including resident rights, elopement incidents, abuse allegations, medication errors, infection control, and quality assurance concerns.
Findings
The facility was found to have multiple deficiencies including failure to inform residents about advance directives, failure to report and investigate elopements resulting in immediate jeopardy, inadequate supervision of residents at risk for wandering, failure to thoroughly investigate abuse and drug diversion incidents, unsafe food storage and sanitation practices, medication administration errors, failure to implement effective infection control screening, and inadequate quality assurance processes.
Deficiencies (9)
Failed to provide information regarding residents' rights to formulate an Advance Directive to 21 of 24 sampled residents.
Failed to timely report incidents of elopement for 2 of 7 sampled residents resulting in Immediate Jeopardy.
Failed to ensure incidents of elopement, staff-to-resident abuse, and drug diversions were thoroughly investigated for 5 of 10 sampled residents.
Failed to ensure a safe environment and provide adequate supervision to prevent elopement for 2 of 7 sampled residents.
Failed to ensure residents were free from significant medication errors when an LPN administered an incorrect dosage of an anticoagulant medication.
Failed to ensure food was stored, prepared, and served under sanitary conditions with multiple observations of build-up and unsanitary conditions in kitchen equipment and practices.
Failed to ensure practices to prevent the spread of infection were maintained when 23 of 121 staff members failed to complete COVID-19 screening prior to working on one day reviewed.
Failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to ensure safety and compliance related to wandering residents and elopement incidents.
Failed to set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action related to wandering and elopement behaviors.
Report Facts
Residents affected: 21
Residents affected: 2
Residents affected: 5
Residents affected: 2
Residents affected: 1
Residents affected: 23
Facility census: 109
Distance: 94.6
Distance: 61.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Administered incorrect dosage of anticoagulant medication |
| CNA #1 | Certified Nursing Assistant | Witnessed Resident #45 elopement |
| LPN #9 | Licensed Practical Nurse | Provided care for Resident #45 on day of elopement |
| Administrator | Administrator | Responsible for facility administration and QAPI oversight |
| DON | Director of Nursing | Responsible for nursing department management and QAPI oversight |
| Staff Development Coordinator | Confirmed high county positivity rate and staff education | |
| Maintenance Director | Measured distances related to elopement incidents and described alarm system | |
| Social Services Director | Confirmed lack of follow-up documentation and reporting of elopements | |
| CNO | Chief Nursing Officer | Educated DON and Administrator on reporting requirements |
Inspection Report
Routine
Deficiencies: 6
Date: Mar 12, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, pressure ulcer management, respiratory care, food and nutrition services, infection prevention and control, and kitchen sanitation.
Findings
The facility was found deficient in developing comprehensive care plans for medication use, documenting pressure ulcer assessments and following physician orders, obtaining physician orders for oxygen therapy, maintaining proper kitchen sanitation and sanitizer testing, ensuring proper hand hygiene and infection control practices, and safe disposal of contaminated lancets.
Deficiencies (6)
Failed to develop a comprehensive Care Plan reflecting current status for antidepressant, anticoagulant, and antianxiety medication use for 2 of 21 sampled residents.
Failed to document assessments and follow physician's orders for pressure injuries for 1 of 2 sampled residents.
Failed to obtain a physician's order for oxygen therapy for 1 of 1 sampled residents.
Failed to employ sufficient staff with appropriate competencies and skills to carry out food and nutrition service functions, including improper sanitizer testing and documentation.
Failed to maintain proper kitchen sanitation including unrestrained facial hair, food open to air in freezer, and incorrect sanitizer test results recorded.
Failed to ensure infection prevention measures including proper hand hygiene during wound care and isolation, and proper disposal of contaminated lancets.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 85
Residents affected: 2
Sanitizer ppm: 120
Sanitizer ppm: 150
Sanitizer ppm: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Performed wound care dressing change without proper hand hygiene; confirmed lack of physician order for oxygen; confirmed infection control deficiencies |
| Dietary Manager | Dietary Manager | Confirmed improper sanitizer testing and documentation; confirmed unrestrained facial hair and food safety issues; confirmed training responsibilities |
| Registered Dietician | Registered Dietician (RD) | Confirmed oversight and training responsibilities for Dietary Manager |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) #1 | Failed to perform hand hygiene after removing PPE in isolation room |
| Licensed Practical Nurse #2 | Licensed Practical Nurse (LPN) #2 | Improperly disposed of contaminated lancet in resident's bathroom trash |
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