Deficiencies (over last year)
Deficiencies (over last year)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% better than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Enforcement
Census: 73
Deficiencies: 2
Date: Jun 3, 2020
Visit Reason
This document is a Consent Order following a life safety complaint investigation and subsequent revisit survey conducted by the Tennessee Department of Health regarding The Pointe at Lifespring assisted-care living facility.
Complaint Details
A life safety complaint investigation was conducted on or about September 12, 2019, triggered by concerns about fire drill evacuation times and documentation.
Findings
The facility failed to evacuate five residents within thirteen minutes during a fire drill and failed to conduct fire drills during sleeping hours with proper documentation. A revisit survey found the facility was unable to evacuate two residents within thirteen minutes during a subsequent fire drill.
Deficiencies (2)
Rule 1200-08-25-.08(8)(a) prohibits retaining residents who cannot evacuate within thirteen minutes. The facility failed to evacuate five residents within thirteen minutes during a fire drill.
Rule 1200-08-25-.10(3)(a) requires quarterly fire drills for each work shift. The facility failed to conduct fire drills during the 2nd or 3rd shifts of 2019 and lacked documentation for these drills.
Report Facts
Residents present during fire drill: 73
Residents not evacuated within 13 minutes: 5
Staff on duty during fire drill: 5
Residents not evacuated within 13 minutes on revisit: 2
Civil monetary penalties: 2500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Mills | Administrator | Signed the Consent Order agreeing to the terms. |
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