Deficiency Records for Ascension Living Alexian Village Tennessee
Updated as of March 01, 2024
A list of the most recent deficiencies for Ascension Living Alexian Village Tennessee. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-13 | 2024-01-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-13 | 2024-01-12 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-13 | 2024-01-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-11 | 2023-11-21 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-10-11 | 2023-11-21 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-11 | 2023-11-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-11 | 2023-11-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-11 | 2023-11-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-11 | 2023-11-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-11 | 2023-11-21 | Y |
| 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. | Health | 2023-10-11 | 2023-11-21 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-10-11 | 2023-11-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-11 | 2023-11-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-11-20 | 2019-12-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-19 | 2019-12-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-11-05 | 2018-12-21 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-11-05 | 2018-12-21 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-11-07 | 2018-12-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-11-07 | 2018-12-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-07 | 2018-12-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-07 | 2018-12-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-11-07 | 2018-12-14 | N |
| 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. | Health | 2018-11-07 | 2018-12-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-07 | 2018-12-14 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2018-11-05 | 2018-12-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-11-05 | 2018-12-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-05 | 2018-12-14 | N |
| Provide housekeeping and maintenance services. | Health | 2017-10-25 | 2017-11-17 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-10-25 | 2017-11-17 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-10-25 | 2017-11-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-10-23 | 2017-11-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-10-23 | 2017-11-17 | N |
