1. 15 Most Frequently Cited Deficiencies Comparative Standard Complaint Life Safety

2. Tennessee Nursing Home Complaint Surveys MOST FREQUENTLY CITED DEFICIENCIES Comparative Tag #Fiscal Year 2009 - Date Tennessee% Surveys TN'09TN'08Nation'09 F0323FACILITY IS FREE OF ACCIDENT HAZARDS3.80%6.30%4.70% F0281SERVICES PROVIDED MEET PROFESSIONAL STANDARDS3.20%3.30%2.60% F0157INFORM OF ACCIDENTS/SIG CHANGES/TRANSFER/ETC1.40%2.50% F0225NOT EMPLOY PERSONS GUILTY OF ABUSE1.40%0.90%2.40% F0514CLINICAL RECORDS MEET PROFESSIONAL STANDARDS1.20%2.50%1.80% F0272COMPREHENSIVE ASSESSMENTS1.20%2.00%0.80% F0309PROVIDE NECESS CARE FOR HIGHEST PRAC WELL BEING1.20%3.80%3.40% F0279DEVELOP COMPREHENSIVE CARE PLANS0.60%1.00%1.30% F0502FACIL PROVIDES/OBTAINS LAB SERVICES0.60% F0250MEDICALLY RELATED SOCIAL SERVICES0.60% F0226POLICIES, PROCEDURES PROHIBIT ABUSE, NEGLECT0.60%1.70%1.30% F0322PROPER CARE & SERVICES FOR RES W/ NG TUBE0.60% F0315RES NOT CATHETERIZED UNLESS UNAVOIDABLE0.60% F0333RESIDENTS FREE FROM SIGNIFICANT MED ERRORS0.60% F0312ADL CARE PROVIDED FOR DEPENDENT RESIDENTS0.30%

3. Tennessee Nursing Home Standard Health Surveys MOST FREQUENTLY CITED DEFICIENCIES Comparative% Surveys Tag #Fiscal Year 2009 - Date TennesseeTN 09TN 08Nation09 F0323FACILITY IS FREE OF ACCIDENT HAZARDS30.00%38.50%36.20% F0371STORE/PREPARE/DISTRIB FOOD UNDER SANITARY CONDS28.50%23.00%34.60% F0431PROPER LABELING OF DRUGS & BIOLOGICALS23.10%17.50%15.60% F0444WASH HANDS WHEN INDICATED23.10%24.60%12.70% F0332MEDICATION ERROR RATES OF 5% OR MORE22.30% F0441FACILITY ESTABLISHES INFECTION CONTROL PROG18.50%20.20%18.40% F0281SERVICES PROVIDED MEET PROFESSIONAL STANDARDS18.50%26.20%26.40% F0280DEVELOPMENT/PREP/REVIEW OF COMP CARE PLAN17.70% F0315RES NOT CATHETERIZED UNLESS UNAVOIDABLE16.90%18.70%18.00% F0514CLINICAL RECORDS MEET PROFESSIONAL STANDARDS16.20%13.90%17.20% F0309PROVIDE NECESS CARE FOR HIGHEST PRAC WELL BEING14.60%26.60%25.40% F0221 RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS NOT REQ'D FOR TREATMENT14.60% F0322PROPER CARE & SERVICES FOR RES W/ NG TUBE13.10% F0164PERSONAL PRIVACY/CONFIDENTIALITY OF RECORDS12.30% F0328PROPER TREATMENT/CARE FOR SPECIAL CARE NEEDS12.30%

4. Tennessee Nursing Home Life Safety Code Surveys MOST FREQUENTLY CITED DEFICIENCIES Comparative% Surveys Tag #Fiscal Year 2009 - Date TennesseeTN 09Region 09Nation 09 K0147ELECTRICAL WIRING AND EQUIPMENT40.00%22.10%27.20% K0062SPRINKLER SYSTEM MAINTENANCE33.60%15.70%28.50% K0067VENTILATING EQUIPMENT22.40%8.10%12.20% K0029HAZARDOUS AREAS - SEPARATION21.60%19.90%27.00% K0025SMOKE PARTITION CONSTRUCTION21.60% 19.80% K0018CORRIDOR DOORS20.80%16.10%27.80% K0052TESTING OF FIRE ALARM20.80%10.20%13.70% K0050FIRE DRILLS18.40%7.70%17.50% K0038EXIT ACCESS16.80%11.00%19.90% K0064PORTABLE FIRE EXTINGUISHERS16.00% K0130OTHER14.40%7.30% K0069COOKING EQUIPMENT11.20%10.10%11.50% K0056AUTOMATIC SPRINKLER SYSTEM10.40%12.70%14.70% K0054SMOKE DETECTOR MAINTENANCE8.80% K0066SMOKING REGULATIONS8.80%

5. Regulation for Admission Agreements 42 CFR 489.22(d)(2) The facility is in violation of its provider agreement – if they charge an individual for failure to remain an inpatient for any agreed-upon length of time or for failure to give advance notice of departure from the providers facility.

6. Registered Nurse Surveyors http://state.tn.us/dohr/JobSearch/Employm ent.html http://state.tn.us/dohr/JobSearch/Employm ent.html Click on Current Openings Go to page 3 Click on Public Health Nurse Consultant 1 debbie.thrasher@tn.gov vincent.davis@tn.gov