Inspection Reports for The Health Center at Richland Place
504 Elmington Avenue, Nashville, TN, 37205
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
4.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 5
Date: Aug 6, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, respiratory care, medication administration, medical record privacy, and infection control practices at The Health Center at Richland Place.
Findings
The facility was found deficient in multiple areas including failure to respect residents' privacy by entering rooms without knocking, improper respiratory care including unsecured oxygen cylinders and undated tubing, administration of respiratory treatments without physician orders, exposure of residents' private medical information during medication administration, and inadequate infection control practices such as failure to perform hand hygiene and clean reusable equipment.
Deficiencies (5)
Failure to provide care and services to promote privacy for residents by staff entering rooms without knocking or asking permission.
Failure to follow physician's orders for oxygen administration and failure to store, change, and date respiratory supplies properly.
Failure to ensure physician orders were written and documented when a resident received respiratory breathing treatments.
Failure to safeguard resident-identifiable information and maintain medical records confidential during medication administration.
Failure to provide and implement an infection prevention and control program including hand hygiene, cleaning of reusable equipment, and proper application of transdermal patches.
Report Facts
Residents sampled for privacy: 5
Residents sampled for respiratory care: 3
Residents sampled for medication administration: 3
Physician order date: Jul 22, 2025
Oxygen setting: 4
Oxygen setting: 6
Physician order date: Feb 27, 2025
Physician order date: Jun 6, 2025
Physician order date: Jul 16, 2025
Nicotine patch dose: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in findings related to oxygen administration, respiratory treatments without physician orders, privacy breaches, and infection control failures. |
| LPN A | Licensed Practical Nurse | Named in findings related to oxygen administration and respiratory treatments without physician orders. |
| LPN C | Licensed Practical Nurse | Named in findings related to entering resident rooms without knocking and infection control failures. |
| CNA H | Certified Nursing Assistant | Named in findings related to entering resident rooms without knocking. |
| CNA J | Certified Nursing Assistant | Named in findings related to entering resident rooms without knocking. |
| Case Worker I | Named in findings related to entering resident rooms without knocking. | |
| RN B | Registered Nurse | Named in findings related to privacy breaches and infection control failures. |
| Director of Nursing | Director of Nursing | Confirmed staff should knock before entering rooms, proper oxygen equipment handling, need for physician orders, privacy protection, and infection control practices. |
| Nurse Practitioner | Nurse Practitioner | Provided assessment and confirmed need for respiratory treatments and physician orders. |
| Respiratory Therapist | Respiratory Therapist | Provided guidance on oxygen equipment maintenance and storage. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 25, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement appropriate care plan interventions and provide adequate supervision for a high-risk resident, resulting in an unwitnessed fall with serious injuries.
Complaint Details
The complaint investigation revealed that Resident #1, who was severely cognitively impaired and at high risk for falls, was left unattended on the side of the bed, resulting in an unwitnessed fall with multiple fractures. The facility failed to provide adequate supervision, failed to conduct a post-fall assessment before moving the resident, and failed to ensure nursing staff had appropriate competencies. The resident was hospitalized and later expired due to complications from the injuries.
Findings
The facility failed to implement appropriate interventions on the care plan for Resident #1, a severely cognitively impaired resident at high risk for falls. Resident #1 had an unwitnessed fall while left unattended on the side of the bed, resulting in multiple fractures and subsequent hospitalization. The facility did not conduct a post-fall assessment before moving the resident, and nursing staff lacked appropriate competencies to ensure resident safety. The resident later expired due to complications from the injuries.
Deficiencies (3)
Failed to implement appropriate care plan interventions for Resident #1 with severe cognitive impairment and fall risk.
Failed to provide adequate supervision and assistance to prevent accidents, resulting in an Immediate Jeopardy due to Resident #1's unwitnessed fall and multiple fractures.
Failed to provide nursing staff with appropriate competencies and skill sets to ensure resident safety, including failure to conduct a post-fall assessment before moving Resident #1 after the fall.
Report Facts
Severity score: 3
Incident date: Dec 11, 2023
Hospital admission date: Dec 11, 2023
Resident expiration date: Dec 28, 2023
Incident report time: 1851
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Assisted in transferring Resident #1 from floor to wheelchair and bed; failed to conduct post-fall assessment |
| LPN C | Licensed Practical Nurse | Notified of Resident #1's fall; assisted with moving resident; documented incident report |
| CNA F | Certified Nursing Assistant | Left Resident #1 unattended on side of bed prior to fall; assisted with moving resident after fall |
| DON | Director of Nursing | Confirmed lack of post-fall assessment and inadequate investigation of fall; unable to verify RN A's training |
| NP | Nurse Practitioner | Approved transfer of Resident #1 to hospital after fall |
| OT | Occupational Therapist | Evaluated Resident #1's fear of movement and need for assistance |
| PT Director | Physical Therapy Director | Reviewed PT and OT evaluations for Resident #1 |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 23, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, care planning, treatment orders, and infection prevention in the nursing facility.
Findings
The facility was found deficient in ensuring personal items were within reach of residents, implementing complete care plans for IV therapy, following physician orders for IV and oxygen therapy, and properly disposing of used IV medication bags and tubing. Deficiencies were noted for multiple residents with minimal harm or potential for actual harm.
Deficiencies (4)
Failed to ensure personal items were within the resident's reach for 1 of 38 residents (Resident #57).
Failed to implement a care plan for midline IV placement, assessment, care, or dressing changes for 1 of 11 residents (Resident #106).
Failed to follow physician's orders for weekly intravenous dressing changes for 1 of 11 residents (Resident #50), and failed to obtain physician's orders for IV therapy for 2 residents (Residents #84 and #106) and oxygen therapy for 1 resident (Resident #344).
Failed to dispose of a used intravenous medication bag and tubing after administration for 1 of 11 residents (Resident #84).
Report Facts
Residents reviewed for IV therapy: 11
Residents reviewed for oxygen therapy: 29
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Confirmed back scratcher and reacher were not within reach for Resident #57 |
| Director of Nursing | Director of Nursing (DON) | Stated essential items should be available and in reach for residents |
| Unit Manager | Reviewed Resident #106's care plan and confirmed no care plan for midline IV placement and dressing changes; confirmed no physician's order for oxygen therapy for Resident #344 | |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Confirmed Resident #50's PICC line dressing was dated and should have been changed weekly |
| Licensed Practical Nurse #3 | Licensed Practical Nurse (LPN) | Confirmed Resident #84 had a midline catheter placed and that IV fluid bag should have been discarded |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Confirmed no physician's order for midline dressing changes for Resident #84 and confirmed empty IV bags should be discarded after infusion |
| Licensed Practical Nurse #2 | Licensed Practical Nurse (LPN) | Confirmed Resident #106 had a midline catheter with dressing dated and that dressing should be changed weekly |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jun 13, 2019
Visit Reason
The inspection was conducted based on complaints and allegations regarding failure to communicate and treat pressure ulcers, failure to notify Ombudsman of resident discharges, failure to provide appropriate pressure ulcer care, failure to prevent falls and conduct complete investigations, failure to post daily staffing and census, failure to obtain laboratory tests properly, and failure to coordinate hospice care.
Complaint Details
The complaint investigation was substantiated with findings of neglect related to pressure ulcer care, failure to notify Ombudsman of discharges, inadequate fall prevention and investigation, failure to post staffing and census, improper lab testing, and failure to coordinate hospice care.
Findings
The facility was found deficient in multiple areas including neglect in pressure ulcer care resulting in worsening ulcers and harm to a resident, failure to notify Ombudsman of discharges for multiple residents, inadequate fall prevention and incomplete fall investigations resulting in harm, failure to update daily staffing and census postings, improper laboratory testing without physician orders, and failure to have an interdisciplinary hospice care plan in place within required timeframes.
Deficiencies (7)
Failure to communicate and document two pressure ulcers causing delay in care and worsening of ulcers resulting in neglect and actual harm.
Failure to send timely notification of discharge/transfer to the Ombudsman for 3 residents.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in actual harm.
Failure to provide supervision to prevent a fall and failure to conduct a complete investigation of the fall resulting in actual harm.
Failure to update the daily posted nurse staffing and census on two days.
Failure to identify a resident prior to obtaining laboratory tests resulting in unnecessary venipunctures.
Failure to have an interdisciplinary care plan between hospice services provider and facility within required timeframe.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 33
Residents affected: 8
Pressure ulcer size: 2
Pressure ulcer size: 1.2
Pressure ulcer size: 1
Pressure ulcer size: 1.8
Pressure ulcer size: 0.3
Pressure ulcer size: 0.2
Braden Score: 13
Fall Risk Assessment Score: 17
Fall Risk Assessment Score: 9
Fall Risk Assessment Score: 18
Pain intensity: 6
Pain intensity: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Wound Care Nurse | Named in pressure ulcer finding; unaware of pressure ulcers until 6/10/19 |
| RN #2 | 3rd Floor Unit Manager and Assistant Director of Nursing | Named in pressure ulcer and fall findings; responsible for Hospital Report Sheet and fall event report |
| CNA #3 | Certified Nursing Assistant | Named in pressure ulcer finding; responsible for skin assessments |
| DON | Director of Nursing | Named in pressure ulcer, fall, lab, and hospice findings; confirmed failures and investigation deficiencies |
| LPN #1 | Licensed Practical Nurse | Named in pressure ulcer finding; spoke with hospice nurse on 6/4/19 |
| LPN #2 | Licensed Practical Nurse | Named in fall finding; administered nebulizer treatment and left resident unattended |
| CNA #2 | Certified Nursing Assistant | Named in fall finding; on duty during fall but did not recall assisting |
| Phlebotomist | Named in lab testing finding; failed to properly identify resident before drawing labs | |
| Hospice RN #3 | Hospice Registered Nurse | Named in hospice finding; assessed pressure ulcers and confirmed hospice care plan delay |
| Hospice RN #7 | Clinical Director of Hospice Provider | Named in hospice finding; confirmed communication and care plan policies |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 27, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to feeding tube administration, nurse staffing postings, dietary food temperature maintenance, and infection prevention and control practices.
Findings
The facility failed to administer the ordered tube feeding formula for one resident, failed to update posted staffing and census information on two days, failed to maintain cold food at or below 41 degrees Fahrenheit, and failed to properly store and date nebulizer equipment for two residents.
Deficiencies (4)
Failed to administer the ordered tube feeding formula (Glucerna 1.2 at 75 ml/hr continuous) and instead administered Glucerna 1.5 for Resident #133.
Failed to update the posted nurse staffing and census information on 6/23/18 and 6/24/18.
Failed to serve cold food at or below 41 degrees Fahrenheit; observed food temperatures ranged from 42 to 52 degrees Fahrenheit.
Failed to store and date nebulizer equipment properly for 2 residents; nebulizer masks were undated and unbagged.
Report Facts
Residents with tube feeding: 5
Tube feeding rate: 75
Tube feeding rate: 60
Food temperature: 52
Food temperature: 50
Food temperature: 47
Food temperature: 48
Food temperature: 42
Nebulizer change frequency: 2
Nebulizer treatments per day: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #3 | Assigned nurse to Resident #133 who confirmed incorrect tube feeding administration | |
| Assistant Director of Nursing (ADON) #1 | Present during observation and interview confirming tube feeding order and administration | |
| Registered Dietitian (RD) #1 | Observed and interviewed regarding failure to maintain cold food temperatures | |
| Registered Nurse (RN) #1 | Present during observation of nebulizer equipment and confirmed improper storage | |
| Registered Nurse (RN) #2 | Confirmed nebulizer masks change frequency and storage requirements |
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