Inspection Reports for The Gardens of Nashville
1022 Eastern Avenue Nashville, NC 27856, Nashville, NC, 27856
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 2, 2025
Visit Reason
The inspection was a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies.
Findings
One deficiency remains related to the facility's fire safety equipment not being maintained in operating condition. Specifically, the annual sprinkler inspection from February 23, 2024, listed several deficiencies, and staff could not provide documentation or a new inspection verifying corrections.
Deficiencies (1)
Facility's fire safety equipment is not maintained in operating condition; failure to maintain could affect occupants during a fire or emergency.
Report Facts
Date of annual sprinkler inspection: Feb 23, 2024
Inspection Report
Annual Inspection
Census: 55
Capacity: 62
Deficiencies: 5
Date: Sep 26, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey and complaint investigations from 09/24/24 to 09/26/24, initiated by a complaint from Nash County Department of Social Services on 08/23/24.
Complaint Details
Complaint investigation initiated by Nash County Department of Social Services on 08/23/24.
Findings
The facility failed to maintain a working call bell system for assisted living residents and failed to ensure shared bathroom sink plumbing was in good condition. Additionally, the facility failed to maintain water temperatures within required ranges and failed to serve therapeutic diets and administer medications as ordered for multiple residents.
Deficiencies (5)
Call bell system was not working properly to alert staff and shared bathroom sink plumbing was not in good condition.
Facility failed to maintain water temperatures at the required minimum of 110°F and maximum of 116°F for 9 of 13 water fixtures in shared and common bathrooms.
Facility failed to serve a therapeutic diet as ordered for Resident #5 with a mechanical soft diet order.
Facility failed to ensure medications were administered as ordered for Residents #5, #6, #7, and #8, including errors with controlled substances, topical gels, and multiple oral medications.
Medication administration records were inaccurate for Resident #6, including medications for acid reflux, depression, heart disease prevention, gastrointestinal health, immune health, seasonal allergies, and dry eyes.
Report Facts
Residents present: 55
Total licensed capacity: 62
Medication error rate: 29
Medication errors: 11
Water fixtures out of temperature range: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding call bell system, water temperature issues, medication administration, and facility operations | |
| Maintenance technician manager | Interviewed regarding call bell system and bathroom sink issues | |
| Medication Aide | Observed administering medications and interviewed regarding medication errors | |
| Dietary Manager | Interviewed regarding therapeutic diet preparation and errors | |
| Cook | Interviewed regarding therapeutic diet preparation | |
| Pharmacy technician | Interviewed regarding medication orders and discrepancies | |
| Resident Care Coordinator | Position vacant; referenced in interviews regarding medication administration oversight |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Jan 24, 2024
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies and to identify any new deficiencies.
Findings
The survey found several deficiencies related to physical plant conditions including non-operable wanderer alarm sounding devices, exterior siding damage, ceiling water stains and peeling, fire safety equipment not maintained in operating condition, gaps and holes in fire resistant rated ceilings, failure of fire doors to latch properly, and lack of exhaust ventilation in specified areas.
Deficiencies (7)
Exit doors override switches' sounding devices were not all operable; specifically, the screamer box at the SCU Dining exit did not alarm when opened.
Outside premises were not maintained in a clean and safe condition; a section of gable exterior siding was popping off over Exit door 3 on the 200 Hall.
Ceilings were not kept in good repair with water stains and peeling finish in the 100 Hall Med Room and kitchen; a gap and cracks were noted around a sprinkler head in the kitchen.
Fire safety equipment was not maintained in operating condition; sprinkler inspection deficiencies from 2022 remained uncorrected, including painted pendant heads, delayed quick opening device, and incomplete main drain flow.
Holes and gaps at penetrations through fire resistant rated ceilings could allow fire and smoke to spread beyond the area of origin, including missing escutcheon rings, unsealed cable penetrations, and deteriorating fire caulk.
Fire resistant rated doors in smoke compartments did not completely close and latch, including cross corridor doors by Rooms 110, 123, and 127.
Facility did not provide exhaust ventilation in specified spaces such as the 100 Hall Housekeeping Closet, several resident bathrooms, Main Laundry, and Housekeeping by Room 223.
Report Facts
Date of sprinkler inspection: Nov 21, 2022
Length of stain: 18
Diameter of holes: 1
Number of water stains: 4
Number of sleeve penetrations: 3
Inspection Report
Follow-Up
Deficiencies: 7
Date: Sep 6, 2023
Visit Reason
This is a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies and to identify any new deficiencies related to the physical plant and safety of the facility.
Findings
The survey identified multiple deficiencies including non-operable wanderer alarm devices, exterior siding damage, water stains and peeling finishes, blocked exit doors, fire safety equipment not maintained or functioning properly, gaps in fire resistant rated ceilings, broken door hardware preventing proper latching, and lack of exhaust ventilation in specified areas.
Deficiencies (7)
Exit doors override switches sounding devices were not all operable; the screamer box at SCU Dining did not alarm when opened.
Outside premises not maintained in a clean and safe condition; exterior siding popping off over Exit door 3 on 200 Hall.
Ceilings not kept in good repair with water stains and peeling finish in multiple rooms including 100 Hall Med Room and Kitchen.
Means of egress or exit paths obstructed; Dining Room exit doors to Dining Porch could not be opened.
Fire safety equipment not maintained in operating condition; sprinkler inspection deficiencies not corrected; gaps and unsealed penetrations in fire resistant rated ceilings throughout facility.
Fire resistant rated doors do not completely close and latch, including cross corridor doors by Rooms 110, 123, and door by Room 127.
Facility did not provide exhaust ventilation in specified spaces including 100 Hall Housekeeping Closet by FACP, restroom near Room 226, several resident bathrooms, Main Laundry, and Housekeeping by Room 223.
Report Facts
Date of sprinkler inspection: Nov 21, 2022
Number of new deficiencies identified: 2
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 8, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on June 8, 2023 and June 9, 2023 to assess compliance with adult care home regulations.
Findings
The facility was found deficient in medication management, including failure to contact the prescribing practitioner for medication clarification for one resident missing insulin doses due to dialysis, and failure to administer medications as ordered for another resident, resulting in a 16% medication error rate during a medication pass.
Deficiencies (2)
Failed to contact the prescribing practitioner for medication clarification for Resident #4 who missed three insulin doses each week due to dialysis.
Failed to ensure medications were administered as ordered for Resident #6, including seasonal allergies medication, vitamin D supplement, and blood thinner.
Report Facts
Medication error rate: 16
Missed insulin doses: 11
Missed insulin doses: 8
Missed insulin doses: 3
Insulin pens on hand: 5
Medication opportunities: 25
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 1, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from 08/31/21 to 09/01/21 to assess compliance with health care and nutrition regulations.
Findings
The facility failed to ensure referral and follow-up for one resident who did not have an eye examination appointment scheduled after a referral, and failed to serve therapeutic diets as ordered for another resident, specifically serving salt to a resident with a no added table salt (NATS) diet order.
Deficiencies (2)
Failed to ensure referral and follow-up for 1 of 5 sampled residents who did not have an appointment scheduled for an eye examination after receiving a referral from the primary care provider.
Failed to serve therapeutic diets as ordered by the physician for 1 of 5 sampled residents who had a diet order for no added table salt (NATS).
Report Facts
Sampled residents: 5
Residents with deficiencies: 1
Dates of survey: 08/31/21-09/01/21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Primary Care Provider | Interviewed regarding Resident #4's diabetic eye examination referral and Resident #3's diet order | |
| Receptionist/Transportation Staff | Interviewed about scheduling and transportation for Resident #4's appointments | |
| Resident Care Coordinator (RCC) | Interviewed about scheduling appointments and diet order communications | |
| Administrator | Interviewed about facility procedures and appointment scheduling | |
| Dietary Manager (DM) | Interviewed about therapeutic diet orders and meal service | |
| Medication Aide (MA) | Observed and interviewed regarding serving salt to Resident #3 |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jan 6, 2016
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on 1/6/2016 to verify correction of previous deficiencies related to facility maintenance and compliance with therapeutic diet menus and resident rights.
Findings
The facility failed to maintain walls, ceilings, and floors in good repair, with multiple areas of torn drywall, stains, and unpainted patches observed. The facility also lacked a matching therapeutic diet menu for residents with physician-ordered no added salt/low concentrated sweets diets. Additionally, residents on the special care unit were denied access to their wardrobe contents due to removal of knobs to prevent theft, violating resident rights.
Deficiencies (3)
Walls and floors in residents' bathrooms, rooms, and hallways were not kept clean and in good repair, including torn drywall, stains, and unpainted patches.
Facility failed to have a matching therapeutic diet menu for 4 sampled residents with no added salt/low concentrated sweets diet orders.
Residents on the special care unit did not have access to their wardrobe contents without staff assistance due to removal of knobs on wardrobe doors and drawers.
Report Facts
Percentage of building issues repaired or repainted: 90
Number of sampled residents without matching therapeutic diet menu: 4
Number of resident rooms with wardrobes missing knobs: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding facility repairs and removal of wardrobe knobs to prevent theft. | |
| Administrator | Interviewed regarding facility repairs, diet menu issues, and removal of wardrobe knobs. | |
| Dietary Manager | Interviewed regarding therapeutic diet menus and staff training on LCS/NAS diet. | |
| Cook | Interviewed regarding meal preparation and diet substitutions. | |
| Registered Dietician | Interviewed regarding development of therapeutic diet menus and LCS/NAS diet instructions. | |
| Director of Operations | Interviewed regarding removal and replacement of wardrobe knobs due to theft complaints. |
Inspection Report
Initial Licensing
Deficiencies: 7
Date: Oct 16, 2015
Visit Reason
The Adult Care Licensure Section conducted an initial survey of Universal Health Care/Nashville from 10/13/2015 to 10/16/2015.
Findings
The facility was found deficient in maintaining a clean and safe physical environment, housekeeping and furnishings, competency validation for licensed health professional support tasks, health care referral and follow-up, nutrition and food service, medication administration, and residents' rights. Specific issues included unsafe outdoor grounds with animal burrows, unclean and damaged resident bathrooms, unlicensed staff applying wound care without competency validation, failure to notify physicians of resident health changes, lack of matching therapeutic diet menus, incomplete medication administration documentation, and failure to ensure residents received adequate care and services.
Deficiencies (7)
The facility failed to assure the outside grounds were maintained in a clean and safe condition related to multiple holes throughout the yard caused by rabbits and burrows.
The facility failed to assure the walls and floors in residents' bathrooms, rooms, and hallways were kept clean and in good repair, including sticky floors, strong odors, stains, holes in walls, peeling paint, and cracked tiles.
The facility failed to assure non-licensed staff were competency validated to apply an unna boot to a resident's foot and leg (Resident #3).
The facility failed to contact the primary care physician for 2 of 5 sampled residents related to bruises and weight loss (Resident #5) and labs not being done (Resident #4).
The facility failed to have a matching therapeutic diet menu for 4 of 8 sampled residents with diet orders for no added salt/no concentrated sweets diets and no concentrated sweets diets.
The facility failed to ensure documentation of medication administration (Prilosec and Coumadin) for 2 of 5 sampled residents (Residents #5 and #4), with multiple dates missing staff initials or comments on the MAR.
The facility failed to assure residents received care and services which were adequate, appropriate, and in compliance with relevant laws related to staff competency validation and referral and follow-up.
Report Facts
Number of rabbits observed: 3
Number of chunks of bread observed: 16
Depth of burrows: 12
Hole size in bathroom wall: 15
Number of baseboards loosened: 3
Number of cracked tiles in hallway: 6
Weight loss: 8.4
Additional weight loss: 2.3
Critical INR lab result: 5.09
Critical INR lab result: 4.49
Medication administration missing documentation: 9
Medication administration missing documentation: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator | Interviewed regarding wound care competency, medication administration, and resident health follow-up. |
| Administrator | Facility Administrator | Interviewed regarding facility deficiencies, corrective actions, and policies. |
| Medication Aide | Medication Aide | Interviewed regarding medication administration and wound care. |
| Dietary Manager | Dietary Manager | Interviewed regarding diet menus and meal preparation. |
| Cook | Cook | Interviewed regarding meal preparation and diet compliance. |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding facility repairs and maintenance issues. |
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