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| Deficiency Category | Inspection Date: 6/17/21 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 7/11/19 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 8/9/18 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: | 6/17/21Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 1/29/25Read the full report (PDF) |
| 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: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 5/1/24 | 5/28/24 | 4 - Immediate jeopardy to resident health or safety | 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 appropriate pressure ulcer care and prevent new ulcers from developing. | 1/29/25 | 2/21/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/1/24 | 10/23/24 | 3 - Actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 5/1/24 | 8/14/24 | 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. | 5/1/24 | 10/2/24 | 3 - Actual harm | Few |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | 5/1/24 | 5/28/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. | 5/1/24 | 5/28/24 | 4 - Immediate jeopardy to resident health or safety | 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. | 5/1/24 | 8/14/24 | 4 - Immediate jeopardy to resident health or safety | 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) |
|---|---|---|---|---|
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 1/29/25 | 2/21/25 | 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. | 5/1/24 | 10/2/24 | 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. | 5/1/24 | 10/23/24 | 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) |
|---|---|---|---|---|
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 5/1/24 | 5/28/24 | 4 - Immediate jeopardy to resident health or safety | 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) |
|---|---|---|---|---|
Reasonably accommodate the needs and preferences of each resident. | 1/29/25 | 2/21/25 | 2 - Minimal harm or potential for actual harm | Few |
Allow residents to self-administer drugs if determined clinically appropriate. | 5/1/24 | 5/28/24 | 2 - Minimal harm or potential for actual harm | Few |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | 5/1/24 | 10/23/24 | 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 that residents are free from significant medication errors. | 5/1/24 | 5/28/24 | 4 - Immediate jeopardy to resident health or safety | Some |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 5/1/24 | 5/28/24 | 2 - Minimal harm or potential for actual harm | Many |
| 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. | 5/1/24 | 5/28/24 | 4 - Immediate jeopardy to resident health or safety | Some |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 5/1/24 | 10/2/24 | 4 - Immediate jeopardy to resident health or safety | Some |
| Date of last standard health inspection: | 7/11/19Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | No complaint inspections |
| 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: |
| 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) |
|---|---|---|---|---|
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | 7/11/19 | 8/9/19 | 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) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 7/11/19 | 8/9/19 | 2 - Minimal harm or potential for actual harm | Some |
| No Resident Assessment and Care Planning Deficiencies were found during this inspection period. |
| 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 dignified existence, self-determination, communication, and to exercise his or her rights. | 7/11/19 | 7/25/19 | 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 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. | 7/11/19 | 8/9/19 | 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: | 8/9/18Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 12/2/22Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | 12/2/22Read the full report (PDF) |
| 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) |
|---|---|---|---|---|
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Respond appropriately to all alleged violations. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | 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) |
|---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | 12/2/22 | 1/4/23 | 3 - Actual harm | Few |
Provide activities to meet all resident's needs. | 8/9/18 | 8/9/18 | 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) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 8/9/18 | 8/31/18 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | 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) |
|---|---|---|---|---|
Ensure services provided by the nursing facility meet professional standards of quality. | 8/9/18 | 8/31/18 | 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) |
|---|---|---|---|---|
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | 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) |
|---|---|---|---|---|
Reasonably accommodate the needs and preferences of each resident. | 8/9/18 | 8/31/18 | 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. | 8/9/18 | 9/9/18 | 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 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. | 8/9/18 | 8/31/18 | 2 - Minimal harm or potential for actual harm | Few |
| 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. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | 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) |
|---|---|---|---|---|
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 5/1/24 | 5/28/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 1/29/25 | 2/21/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/1/24 | 10/23/24 | 3 - Actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 5/1/24 | 8/14/24 | 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. | 5/1/24 | 10/2/24 | 3 - Actual harm | Few |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | 5/1/24 | 5/28/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. | 5/1/24 | 5/28/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide and implement an infection prevention and control program. | 5/1/24 | 8/14/24 | 4 - Immediate jeopardy to resident health or safety | Some |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 1/29/25 | 2/21/25 | 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. | 5/1/24 | 10/2/24 | 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. | 5/1/24 | 10/23/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 5/1/24 | 5/28/24 | 4 - Immediate jeopardy to resident health or safety | Some |
Reasonably accommodate the needs and preferences of each resident. | 1/29/25 | 2/21/25 | 2 - Minimal harm or potential for actual harm | Few |
Allow residents to self-administer drugs if determined clinically appropriate. | 5/1/24 | 5/28/24 | 2 - Minimal harm or potential for actual harm | Few |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | 5/1/24 | 10/23/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 5/1/24 | 5/28/24 | 4 - Immediate jeopardy to resident health or safety | Some |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 5/1/24 | 5/28/24 | 2 - Minimal harm or potential for actual harm | Many |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 5/1/24 | 5/28/24 | 4 - Immediate jeopardy to resident health or safety | Some |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 5/1/24 | 10/2/24 | 4 - Immediate jeopardy to resident health or safety | Some |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Respond appropriately to all alleged violations. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | 12/2/22 | 1/4/23 | 3 - Actual harm | Few |
Provide and implement an infection prevention and control program. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | Some |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | 12/2/22 | 1/4/23 | 4 - Immediate jeopardy to resident health or safety | Some |
| This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years. |