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| Deficiency Category | Inspection Date: 9/25/24 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 11/20/19 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 11/7/18 Complaint Reporting Period: 4/1/22 - 3/31/23 |
|---|---|---|---|
| Freedom from Abuse, Neglect, and Exploitation Deficiencies | |||
| Quality of Life and Care Deficiencies | |||
| Infection Control Deficiencies | |||
| Resident Assessment and Care Planning Deficiencies | |||
| Nursing and Physician Services Deficiencies | |||
| Resident Rights Deficiencies | |||
| Nutrition and Dietary Deficiencies | |||
| Pharmacy Service Deficiencies | |||
| Environmental Deficiencies | |||
| Administration Deficiencies |
| Date of last standard health inspection: | 9/25/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | |
| Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Tennessee: | |
| Average number of Health Deficiencies in the United States: |
| No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
| No Quality of Life and Care Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 9/25/24 | 10/12/24 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 8/7/24 | 9/1/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 8/7/24 | 9/1/24 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 9/25/24 | 10/12/24 | 2 - Minimal harm or potential for actual harm | Few |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | 9/25/24 | 10/12/24 | 2 - Minimal harm or potential for actual harm | Few |
| No Nutrition and Dietary Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 8/7/24 | 9/1/24 | 2 - Minimal harm or potential for actual harm | Few |
| No Environmental Deficiencies were found during this inspection period. |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 11/20/19Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | 12/13/23Read the full report (PDF) 10/11/23Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Tennessee: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 12/13/23 | 1/12/24 | 2 - Minimal harm or potential for actual harm | Some |
Respond appropriately to all alleged violations. | 12/13/23 | 1/12/24 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from the wrongful use of the resident's belongings or money. | 10/11/23 | 11/21/23 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | 10/11/23 | 11/21/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 10/11/23 | 11/21/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/11/23 | 11/21/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 10/11/23 | 11/21/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 11/20/19 | 12/20/19 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 10/11/23 | 11/21/23 | 2 - Minimal harm or potential for actual harm | Many |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 10/11/23 | 11/21/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 10/11/23 | 11/21/23 | 4 - Immediate jeopardy to resident health or safety | Few |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 10/11/23 | 11/21/23 | 2 - Minimal harm or potential for actual harm | Few |
| No Nutrition and Dietary Deficiencies were found during this inspection period. |
| No Pharmacy Service Deficiencies were found during this inspection period. |
| No Environmental Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 10/11/23 | 11/21/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 12/13/23 | 1/12/24 | 2 - Minimal harm or potential for actual harm | Few |
| Date of last standard health inspection: | 11/7/18Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | No complaint inspections |
| Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Tennessee: | |
| Average number of Health Deficiencies in the United States: |
| No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 11/7/18 | 12/14/18 | 2 - Minimal harm or potential for actual harm | Few |
| No Infection Control Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 11/7/18 | 12/14/18 | 2 - Minimal harm or potential for actual harm | Few |
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | 11/7/18 | 12/14/18 | 2 - Minimal harm or potential for actual harm | Few |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | 11/7/18 | 12/14/18 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 11/7/18 | 12/14/18 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 11/7/18 | 12/14/18 | 2 - Minimal harm or potential for actual harm | Few |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 11/7/18 | 12/14/18 | 2 - Minimal harm or potential for actual harm | Few |
| No Environmental Deficiencies were found during this inspection period. |
| No Administration Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 8/7/24 | 9/1/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 8/7/24 | 9/1/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 8/7/24 | 9/1/24 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 12/13/23 | 1/12/24 | 2 - Minimal harm or potential for actual harm | Some |
Respond appropriately to all alleged violations. | 12/13/23 | 1/12/24 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from the wrongful use of the resident's belongings or money. | 10/11/23 | 11/21/23 | 2 - Minimal harm or potential for actual harm | Some |
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | 10/11/23 | 11/21/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 10/11/23 | 11/21/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/11/23 | 11/21/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 10/11/23 | 11/21/23 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 10/11/23 | 11/21/23 | 2 - Minimal harm or potential for actual harm | Many |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 10/11/23 | 11/21/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 10/11/23 | 11/21/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 10/11/23 | 11/21/23 | 2 - Minimal harm or potential for actual harm | Few |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 10/11/23 | 11/21/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 12/13/23 | 1/12/24 | 2 - Minimal harm or potential for actual harm | Few |
| This nursing home has not had any infection control inspections in the past 3 years. |