GRACE HEALTHCARE OF FRANKLIN

Nursing Home Inspector

1287 WEST MAIN
FRANKLIN, TN 37064
Williamson County
Phone: 615-794-8417
Provider Number: 445146
Last Inspection: 03/08/2017

About the Nursing Home

Number of Beds: 88
Number of Residents: 71
Beds Available: 17
Percent Occupancy: 81%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

27

Facility
15

County
14

TN
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

27

2017
22

2015
37

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

3/8/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 4/8/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Isolated : Minimal 3 4/8/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 4/8/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 4/8/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 3/24/2017
 
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 4/8/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Pattern : Minimal 4 3/29/2017
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 4/8/2017
 

12/9/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 1/8/2016
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 1/8/2016
 
Failed To: Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. Widespread : Minimal 5 1/8/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 1/8/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 1/8/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 1/8/2016
 

10/23/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 11/21/2014
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 11/21/2014
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 11/21/2014
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 11/21/2014
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 11/21/2014
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 11/21/2014
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 11/21/2014
 
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 11/21/2014
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 11/21/2014
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Minimal 4 11/21/2014
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 11/21/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

4/5/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 4/29/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg TN State Avg
Number of Residents 71 88.00 85.33
Registered Nurses 0.48 0.84 0.75
Licensed Practical / Vocational Nurses 0.99 0.90 1.05
Certified Nursing Assistants 1.60 2.05 2.17
Total Staff Hours 3.06 3.78 3.97

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% TN State Avg%
of high risk long-stay residents with pressure ulcers 7 4 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 89 93 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 84 87 93
of long-stay residents experiencing one or more falls with major injury 5 3 3
of long-stay residents who have depressive symptoms 2 0 2
of long-stay residents who lose too much weight 14 7 7
of long-stay residents who received an antianxiety or hypnotic medication 32 23 36
of long-stay residents who received an antipsychotic medication 27 20 17
of long-stay residents who self-report moderate to severe pain 0 3 4
of long-stay residents who were physically restrained 0 0 1
of long-stay residents whose ability to move independently worsened 25 26 21
of long-stay residents whose need for help with daily activities has increased 19 17 15
of long-stay residents with a catheter inserted and left in their bladder 1 1 2
of long-stay residents with a urinary tract infection 6 5 4
of low risk long-stay residents who lose control of their bowels or bladder 78 55 56
of short-stay residents assessed and appropriately given the pneumococcal vaccine 67 85 83
of short-stay residents who had an outpatient emergency department visit 16 12 13
of short-stay residents who made improvements in function 59 64 64
of short-stay residents who newly received an antipsychotic medication 5 2 2
of short-stay residents who self-report moderate to severe pain 5 9 12
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 56 77 81
of short-stay residents who were rehospitalized after a nursing home admission 21 19 21
of short-stay residents who were successfully discharged to the community 41 52 48
of short-stay residents with pressure ulcers that are new or worsened 0 0 0