Deficiencies (last 4 years)
Deficiencies (over 4 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
42 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 5
Jul 23, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements related to care plans, respiratory care, sanitation, infection control, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to revise a resident's care plan to reflect preferences, improper dating and storage of respiratory disposables, inadequate containment and sanitation of garbage dumpsters, failure to maintain sanitary conditions and hand hygiene assistance for residents, and physical therapy equipment in disrepair.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to revise the care plan for Resident #142 to include preference for use of 4 side rails in the up position. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly date and store a nasal cannula for Resident #220 and an inline suction catheter for Resident #147. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure garbage and refuse were properly contained in 1 of 3 dumpsters and maintain the dumpster area in a sanitary condition. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure biohazard waste was contained properly for Resident #3, maintain sanitary environment for Resident #95, and offer hand hygiene assistance prior to meals to 5 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain 2 Physical Therapy Gym mat platform tables in good repair; tables had large rips and tears exposing foam padding. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for care plans: 42
Residents reviewed for oxygen therapy: 7
Residents sampled with inline suction catheters: 11
Dumpsters observed: 3
Physical Therapy Gym mat platform tables: 2
Residents observed on transmission based precautions: 6
Residents observed for sanitary environment: 4
Residents observed for hand hygiene assistance: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) C | Confirmed Resident #142 had 4 side rails up in bed | |
| Licensed Practical Nurse (LPN) D | Confirmed Resident #142 had 4 side rails up in bed | |
| Director of Nursing (DON) | Confirmed Resident #142's care plan was not revised to include side rail preference; stated staff expectation for hand hygiene assistance | |
| Licensed Practical Nurse (LPN) E | Confirmed Resident #142's care plan was not revised to include side rail preference | |
| Respiratory Therapist (RT) B | Confirmed Resident #147's inline suction catheter was undated and staff did not follow policy | |
| Director of Respiratory Care | Confirmed respiratory disposables should be dated and stored properly; confirmed policy noncompliance | |
| 2 West/2 East Assistant Unit Manager | Confirmed nasal cannula was undated and not stored properly | |
| Dietary Manager | Confirmed dumpster area was not maintained properly | |
| Unit Manager | Unaware biohazard trash container was overflowing and held cubicle curtains | |
| Certified Nursing Assistant (CNA) A | Failed to offer hand hygiene assistance to multiple residents prior to meals | |
| 2 East/West Unit Manager | Confirmed expectation for staff to offer hand hygiene assistance prior to meals | |
| Director of Therapy | Confirmed Physical Therapy Gym mat platform tables were in disrepair and needed replacement |
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 27, 2023
Visit Reason
The inspection was conducted due to complaints regarding unsanitary and unclean conditions in resident rooms and bathrooms for two residents (#17 and #18) at the facility.
Findings
The facility failed to maintain clean, comfortable, sanitary, and homelike conditions for Residents #17 and #18. Observations and interviews confirmed unsanitary conditions including water stains, debris, sticky floors, fecal material in the toilet, and unclean bathrooms, which did not meet facility standards.
Complaint Details
The visit was complaint-related due to grievances filed by Resident #17's family regarding care concerns and room conditions starting at admission. The Administrator and Housekeeping Services Director confirmed the complaints and acknowledged the failure to meet cleaning standards.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain clean, comfortable, sanitary, and homelike conditions in resident rooms and bathrooms for Residents #17 and #18. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Services Director | Interviewed regarding complaints and inspection of Resident #17's room and bathroom conditions. | |
| Administrator | Interviewed and confirmed failure to maintain clean and sanitary conditions; responded to family complaints. | |
| Director of Nursing (DON) | Mentioned as having raised complaints about room conditions to the Housekeeping Services Director. |
Inspection Report
Annual Inspection
Deficiencies: 4
Jun 9, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, and pre-admission screening at The Health Center at Standifer Place.
Findings
The facility was found deficient in multiple areas including failure to submit a PASRR Level II evaluation for a resident with new diagnoses, failure to provide restorative nursing care as ordered, failure to address pharmacist recommendations for unnecessary medications, and failure to ensure proper infection control practices for a resident under transmission-based precautions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to submit a PASRR Level II evaluation for a resident after new diagnoses of Dementia with Behavioral Disturbances and Delusional Disorder. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide restorative nursing care for a resident as ordered, with no restorative services provided since 4/19/2022. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to address the pharmacist's recommendations for unnecessary medications for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure infection control practices were followed for a resident on transmission-based precautions, including failure to don gown and gloves. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for PASRR Level II evaluation: 6
Residents reviewed for restorative nursing care: 10
Residents reviewed for unnecessary medications: 5
Residents reviewed for transmission-based precautions: 4
Minutes of occupational therapy services: 170
Minutes of physical therapy services: 134
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Stated she had not observed therapy/restorative working with Resident #91 recently |
| Director of Therapy and Restorative Services | Director of Therapy and Restorative Services | Confirmed Resident #91 had not received restorative services since 4/19/2022 |
| Director of Nursing | Director of Nursing | Confirmed pharmacy recommendation for Resident #114 was not addressed and confirmed expectation for staff to wear appropriate PPE |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Did not don gown or gloves when entering Resident #540's room under transmission-based precautions |
| Unit Manager #1 | Unit Manager | Confirmed Resident #540 was in transmission-based precautions and expectation for staff to don PPE |
| Unit Manager #2 | Unit Manager | Confirmed expectation for staff to don appropriate PPE for residents in transmission-based precautions |
| Physical Therapy Assistant Director | Physical Therapy Assistant Director | Stated restorative had not seen Resident #91 since 4/19/2022 |
| MDS Coordinator | MDS Coordinator | Confirmed PASRR Level II was not submitted for Resident #193 after new diagnoses |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 6
Jul 31, 2019
Visit Reason
The inspection was conducted due to complaints regarding failure to refund resident trust fund balances, failure to refer a resident for PASARR screening, failure to implement a comprehensive care plan for pain management, failure to provide timely pain medication administration, inadequate nursing staffing levels, and significant medication errors.
Findings
The facility failed to refund resident trust fund balances timely for discharged residents, failed to refer a resident with a serious mental illness for PASARR Level II screening, failed to implement and follow a comprehensive pain management care plan resulting in late medication administration and increased pain for a resident, failed to maintain adequate nursing staffing levels leading to delayed medication administration, and failed to ensure a resident was free from significant medication errors.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed in multiple areas including refunding resident trust funds, PASARR referrals, pain management care planning and medication administration, staffing adequacy, and medication error prevention.
Severity Breakdown
Level of Harm - Potential for minimal harm: 1
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to refund the balance of a Patient Trust Fund within the required time frame for 2 discharged residents. | Level of Harm - Potential for minimal harm |
| Failed to refer 1 resident identified with a possible serious mental disorder to the state-designated authority for a Level II PASARR evaluation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement a comprehensive care plan for pain management for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely administration of pain medication resulting in increased pain for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain adequate nursing staffing levels to ensure timely administration of medications for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure 1 resident was free from significant medication errors. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Patient Trust Funds reviewed: 313
Residents reviewed for PASARR: 37
Residents reviewed for pain: 37
Resident census: 53
Medication administration delays: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Reported medications often administered late due to staffing shortages |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Reported medication administration delays and staffing shortages |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Reported nurses frequently pulled to other floors leaving one nurse for 53 residents |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Reported difficulty administering medications on time when one nurse on duty |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Reported difficulty administering medications on time when one nurse on duty |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Called in to cover night shift due to nurse absence |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Pulled to another floor leaving one nurse on 2 East Unit |
| Director of Nursing | Director of Nursing | Confirmed medication administration time frames and staffing issues |
| Medical Director | Medical Director | Confirmed expectations for timely medication administration and risks of delays |
| Shift Supervisor | Shift Supervisor | Covered 2 East Unit during nurse absence but was not always present on unit |
| 2 East Unit Manager | Unit Manager | Reported medication delays due to staffing shortages and additional duties |
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