JEFFERSON COUNTY NURSING HOME
Government - City/county
160 Beds
Independent
Data: November 2025
Trust Grade
60/100
#127 of 298 in TN
Photo by joy Kirby
Photo by Trisha Woods
Photo by Ashley Whitehead
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Last Inspection: August 2022
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
Jefferson County Nursing Home in Dandridge, Tennessee has a Trust Grade of C+, indicating it is decent and slightly above average compared to other facilities. It ranks #127 out of 298 in the state, placing it in the top half, and is the best option out of three facilities in Jefferson County. However, the facility's trend is worsening, as the number of issues noted increased from 1 in 2019 to 5 in 2022. Staffing is a positive aspect, with a 4 out of 5 star rating and a turnover rate of 33%, which is significantly better than the state average of 48%. On the downside, there are concerning incidents, including a serious failure to transfer a resident properly, resulting in a fractured femur, and issues with kitchen sanitation that could affect residents' health. Overall, while there are strengths, families should be aware of the reported problems and the facility's declining trend.
- Trust Score
- C+
- In Tennessee
- #127/298
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 33% turnover. Near Tennessee's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Tennessee facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 24 minutes of Registered Nurse (RN) attention daily — below average for Tennessee. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ○ Average
- 8 deficiencies on record. Average for a facility this size. Mostly minor or procedural issues.
60/100
Top 42%
Needs review
1 → 5 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2019: 1 issues
2022: 5 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (33%)
15 points below Tennessee average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
3-Star Overall Rating
Near Tennessee average (2.8)
Meets federal standards, typical of most facilities
Staff Turnover: 33%
13pts below Tennessee avg (46%)
Typical for the industry
The Ugly 8 deficiencies on record
2 actual harm
Nov 2022
2 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Comprehensive Care Plan
(Tag F0656)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation and interview the facility failed to ensure 1 resident (Residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation and interview the facility failed to ensure 1 resident (Resident #1) of 3 sampled residents was transferred according to the comprehensive care plan which resulted in a fracture to Resident #1's right femur and harm for Resident #1.
The findings included:
Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia, Mood Disorder, Foot Drop Right and Left Feet and Rheumatoid Arthritis.
Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident was severely cognitively impaired. The resident was totally dependent for transfers with 2-person assist.
Medical record review of Resident #1's comprehensive care plan dated 7/10/2019 showed Resident #1 was totally dependent on staff for all activities of daily living (ADLs) and for transfers . Maxi lift [a mechanical lift with the use of a sling that is placed underneath a resident, the sling is attached to a mechanical lift which allows the resident's weight to be lifted and the resident can then be transferred to a different location] .
Medical record review of a nurse note dated 11/9/2022 at 3:34 PM showed Resident #1's Power of Attorney (POA) was notified of an increase in pain to Resident #1's right lower extremity and the Physician Assistant (PA) had ordered an x-ray.
Medical record review of a Radiology Report dated 11/9/2022 at 6:10 PM showed Resident #1 had sustained a fracture .Conclusion: Recent distal femoral fracture .
Medical record review of the hospital History and Physical dated 11/9/2022 confirmed Resident #1 was admitted to the hospital with a right femur fracture.
Review of a facility investigation dated 11/9/2022 showed the facility initiated an immediate investigation after Resident #1 was discovered to have a distal femur fracture. The facility's investigation revealed Certified Nurse Assistant (CNA) #1 had requested assistance from CNA #2 to help transfer Resident #1 from the bed to her wheelchair. Investigation review revealed CNA #2 entered Resident #1's room, sat Resident #1 up on the side of the bed and without the use of the mechanical lift, CNA #2 placed her arms around Resident #1's waist, picked the resident up and sat the resident down in the wheelchair. The facility's investigation revealed Resident #1's right leg was caught underneath her buttocks during the transfer. Further review revealed CNA #2 told CNA #1 she had reported the incident to a nurse, however she did not.
During an interview on 11/15/2022 at 10:05 AM CNA #1 confirmed she was aware Resident #1 required the use of a mechanical lift to transfer Resident #1 to her wheelchair however stated CNA #2 seemed rushed and transferred the resident without the use of the mechanical lift.
Interview on 11/16/2022 at 11:05 AM with the Director of Nursing (DON) confirmed CNA #2 did not follow Resident #1's care plan for the use of a mechanical lift for transfers which resulted in a fracture to Resident #1's right femur.
Interview with CNA #2 on 11/16/2022 at 2:00 PM by phone confirmed CNA #2 was aware Resident #1 required the use of a mechanical lift for transfers and had not used one when she transferred Resident #1 from the bed to the wheelchair.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of facility investigation and interview the facility failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of facility investigation and interview the facility failed to ensure 1 resident (Resident #1) of 3 sampled residents was transferred with the use of a mechanical lift which resulted in a fracture to Resident #1's right femur and harm for Resident #1.
The findings included:
Review of a facility policy Resident Lifting Policy effective 9/18/1997 showed .[facility] will be considered a 'LIFT FREE FACILITY' .mechanical lifts will be provided to do all types of lifting and transferring of residents .
Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia, Mood Disorder, Foot Drop Right and Left Feet and Rheumatoid Arthritis.
Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident was severely cognitively impaired. The resident was totally dependent for transfers with 2-person assist. Resident #1 was only able to stabilize with staff assistance for surface-to-surface transfers between bed and chair or wheelchair.
Medical record review of Resident #1's comprehensive care plan dated 7/10/2019 showed Resident #1 required .total assistance with the following activities of daily living [ADLS]: bed mobility, transfers, bathing, grooming/hygiene, dressing, toileting, and eating. Non-ambulatory. Has contracture to right hand, bilateral foot drop. Maxi lift [a mechanical lift with the use of a sling that is placed underneath a resident, the sling is attached to a mechanical lift which allows the resident's weight to be lifted and the resident can then be transferred to a different location] for transfers .
Medical record review of a nurse note dated 11/9/2022 at 3:34 PM showed .POA [Power of Attorney] notified of c/o [complaint of] increased pain to RLE [Right Lower Extremity]. Physician Assistant [PA] assessed resident. New orders received .Resident resting in bed at this time .
Medical record review of a Radiology Report dated 11/9/2022 at 6:10 PM showed .Conclusion: Recent distal femoral fracture .
Medical record review of a nurse note dated 11/9/2022 at 7:14 PM showed the radiology report was received at the facility, the PA was notified and ordered Resident #1 be sent to the hospital for an orthopedic evaluation and the POA was notified.
Medical record review of the hospital History and Physical dated 11/9/2022 confirmed Resident #1 was admitted to the hospital with a right femur fracture.
Review of a facility investigation dated 11/9/2022 showed the facility initiated an immediate investigation after Resident #1 was discovered to have a distal femur fracture. The facility's investigation revealed Certified Nurse Assistant (CNA) #1 dressed Resident #1 for breakfast and requested assistance from CNA #2 to transfer Resident #1 using the mechanical lift. CNA #2 entered Resident #1's room and told CNA #1 she would show her how to transfer the resident. CNA #2 sat Resident #1 up on the side of her bed, placed her arms around the resident's waist, picked the resident up and sat her over into her wheelchair without the use of the mechanical lift. The resident bent her right knee during the transfer and her leg was caught underneath her buttocks. CNA #1 told CNA #2 the resident's leg was underneath her. CNA #2 lifted the resident up by placing her arms around her waist and CNA #1 straightened the resident's leg. CNA #2 sat the resident back down in the wheelchair and the resident's feet were placed on the wheelchair's footrest. Resident #1 did not express pain at the time of the incident. CNA #2 told CNA #1 she had reported the transfer incident to the nurse, but investigation revealed CNA #2 did not report the incident. Registered Nurse (RN) #1 noted edema to Resident #1's right knee and an x-ray of the right knee was ordered. The x-ray results showed a recent right femur fracture. Resident #1 was transferred to the hospital for treatment.
Interview on 11/15/2022 at 8:45 AM with the Administrator confirmed the facility began an investigation immediately when they became aware of the fracture to Resident #1's right femur. Statements were obtained from all staff that had provided care for Resident #1 for the previous 24 hours. The witness statements revealed CNA #2 had transferred Resident #1 improperly and the resident's right leg was caught underneath her as she was placed in her wheelchair.
During an interview on 11/15/2022 at 10:05 AM CNA #1 confirmed she was aware Resident #1 required the use of a lift to transfer Resident #1. CNA #1 stated CNA #2 entered Resident #1's to assist with the transfer and told CNA #1 she would show her how it was done. CNA #2 then sat Resident #1 up on the side of the bed, placed her arms around the resident's waist, picked her up and sat her down in her wheelchair. CNA #1 stated Resident #1 bent her right leg during the transfer and CNA #2 sat the resident down with the resident's right leg bent underneath her. CNA #1 stated CNA #2 seemed rushed. CNA #1 stated she then took Resident #1 to the dining room and assisted her with breakfast and on the way back to Resident #1's room the resident complained of knee pain and CNA #1 reported the complaint of pain to Licensed Practical Nurse (LPN) #1. CNA #1 stated when she transferred Resident #1 to provide incontinence care before the end of her shift at 2:00 PM Resident #1 continued to complain of knee pain, and she then reported the pain to the supervisor Registered Nurse (RN) #1.
Interview on 11/15/2022 at 11:10 AM with LPN #1 confirmed he was Resident #1's nurse on 11/9/2022 and confirmed CNA #1 reported the resident's complaint of knee pain. LPN #1 stated it was time for Resident #1's routine pain medications, so he administered the medication to Resident #1. LPN #1 stated he was unaware of the incorrect transfer of Resident #1 and was not informed by CNA #2 of the incident. Continued interview with LPN #1 revealed RN #1 later reported to him Resident #1 continued to complain of knee pain and RN #1 and the PA assessed the resident's right knee and it appeared swollen. They applied scheduled topical pain cream to Resident #1's bilateral knees and the PA ordered an x-ray to the right knee.
During a telephone interview on 11/16/2022 at 10:45 AM with RN #1 revealed CNA #1 reported Resident #1 complained of continued knee pain later in the CNA's shift on 11/9/2022. Continued interview confirmed RN #1 and the PA assessed the resident 's knee and it appeared swollen. The PA ordered an x-ray of the right knee due to the swelling and the increased complaints of knee pain. RN #1 stated she was not aware of the incorrect transfer at the time she and the PA assessed Resident #1.
Interview on 11/16/2022 at 11:05 AM with the Director of Nursing (DON) confirmed CNA #2 did not follow Resident #1's care plan for transfers which resulted in a fracture to Resident #1's right femur.
Interview with CNA #2 on 11/16/2022 by phone at 2:00 PM confirmed CNA #2 was aware Resident #1 required the use of a mechanical lift for transfers and had not used one when she transferred Resident #1 from the bed to the wheelchair.
Aug 2022
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review, observation, and interview, the facility failed to complete an asses...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review, observation, and interview, the facility failed to complete an assessment for self-administration of medications by the interdisplinary team for 1 resident (Resident #141) of 27 residents observed.
The findings include:
Review of the facility policy titled, Resident Self Administration Policy, dated 6/7/2022, revealed .In order for a resident to be considered for self-administration of medication .assessment will be performed by a nursing team member to ensure that the resident is safe to administrator and the medication is safe to be administered .if assessment meets criteria, an order will be obtained from medical provider, a lock box will be provided for resident in room with a key .
Resident #141 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Respiratory Failure, Emphysema, Hypertension, and Chronic Obstructive Pulmonary Disease.
Review of Resident #141's care plan dated 4/28/2022, showed no documentation for self-administration of medications.
Review of Resident #141's Minimum Data Set quarterly assessment dated [DATE], showed Brief Interview of Mental Status score was 13 which indicated resident was cognitively intact, and resident was independent with eating.
During an observation on 8/15/2022 at 10:13 AM, showed Normal saline nasal spray (spray used to moisten inside of nose) and Oymetazoline nasal solution (medication spray to relieve nose stuffiness) nose spray at bedside for resident use.
During an interview on 8/15/2022 at 11:45 AM, the Director of Nursing (DON) confirmed the medications were at the resident's bedside for resident use and should not have been stored in the resident's room. The DON stated Resident #141 had not been assessed for self-administration of medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Centers for Disease Control (CDC) guidance, review of the facility policy, review of facility documentati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Centers for Disease Control (CDC) guidance, review of the facility policy, review of facility documentation, observation, and interview, the facility failed to ensure 1 of 1 COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) unvaccinated staff observed donned appropriate Personal Protective Equipment (PPE) to ensure precautions were taken to properly prevent COVID-19 transmission to 5 of 113 residents in the facility.
The findings include:
Review of the CDC guidance titled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, dated 2/2/2022, showed .HCP [health care personnel] who are not up to date with all recommended COVID-19 doses .Residents .cared for by HCP using an N95 or higher-level respirator .
Review of the facility policy titled, COVID-19 Vaccination Policy, dated 4/22/2022, showed .to help reduce the risk residents and staff have of contracting and spreading COVID-19 .Staff who receive an exemption to the COVID-19 vaccine will be subject to additional precautions which includes [include] .Requiring unvaccinated staff to use .N-95 [respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles] .
Review of the facility's COVID-19 Staff Vaccination Status for Providers document showed Certified Nursing Assistant (CNA) #2 had a COVID-19 religious vaccination exemption.
Review of facility test reporting showed CNA #2 had a negative COVID-19 test at the beginning of shift on 8/17/2022.
Review of CNA #2's resident assignment for 8/17/2022, revealed the CNA was assigned to care for 5 residents (#92, #30, #100, #107 and a newly admitted resident) on the same hall.
Resident #92 was admitted on [DATE] with Non-Traumatic Brain Dysfunction. The resident was fully vaccinated and had received the booster for Covid-19.
During an observation on 8/17/2022 at 9:00 AM, CNA #2 wore a surgical mask and was not wearing an N-95 mask as she exited Resident #92's room.
During an interview on 8/17/2022 at 9:10 AM, CNA #2 confirmed she was unvaccinated, and .I am supposed to wear an N-95 . in the facility. CNA #2 stated she was had asthma symptoms at the beginning of the shift, supervisor was informed, and testing was performed for COVID-19 on the morning of 8/17/2022. CNA #2 stated a N-95 mask was not worn because of shortness of breath.
During an observation and interview on 8/17/2022 at 9:20 AM, the Infection Preventionist confirmed CNA #2 was not wearing an N-95 mask, and there were no shortages of N-95 masks in the facility. The Infection Preventionist stated it was expected unvaccinated staff wear a N-95 at all times in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on facility policy review, observation, and interview the facility failed to maintain a sanitary kitchen with open to air food items/unsealed food items in 1 of 2 bread racks. The facility faile...
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Based on facility policy review, observation, and interview the facility failed to maintain a sanitary kitchen with open to air food items/unsealed food items in 1 of 2 bread racks. The facility failed to maintain kitchen equipment in a sanitary manner in 1 of 1 kitchen. The facility failed to maintain a sanitary kitchen with open to air/unsealed food items, not placed in a container after opened, in 1 of 2 food preparation tables. The facility failed to maintain a sanitary kitchen with open to air/unsecured, undated with an open date, and undated food items with a use by date in 1 of 1 walk in freezers. The facility failed to maintain a sanitary kitchen with open to air/unsealed, undated with an open date, undated with a use by date in 1 of 1 walk in refrigerators in 1 of 1 kitchen potentially affecting 114 of 116 residents.
The findings include:
Review of the facility's policy, Food Storage, dated 3/25/2012, revealed .Food is stored and prepared in a clean safe sanitary manner .Purpose .To minimize contamination and bacteria .All food items opened should have open date and be sealed .
Review of the facility's policy, Dry Food Storage, dated 3/26/2012, revealed .Purpose .To ensure dry food is stored in a safe, sanitary manner to ensure the best food quality .Open food items will be stored in clean, dry, sealed containers with contents noted and opened dates .
Review of the facility's policy, Cold Storage Area, dated 4/1/2021, revealed .Cold food(s) will be stored under safe and sanitary conditions .Date, label, and properly secure all products removed from original containers with all items labeled stating the contents inside, the date opened, and the appropriate use-by date .
Review of the facility's policy, Equipment Cleaning, undated, revealed .Purpose .To ensure food safety .All equipment including drawers, trays, and surfaces should be clean and free of debris .
During an observation on 8/15/2022 at 10:23 AM, of the bread rack, in the kitchen with the Dietary Manager (DM) revealed:
-3 slices of whole wheat bread in a clear plastic bag, open to air/unsealed, and available for resident use.
-1 hamburger bun in a clear plastic bag, open to air/unsealed, and available for resident use.
-8 slices of white bread in a plastic bag, open to air/unsealed, and available for resident use.
During an interview on 8/15/2022 at 10:26 AM, the Dietary Manager (DM) confirmed the bread on the bread rack was available for resident consumption and was open to air and unsealed. The DM confirmed the facility failed to maintain a sanitary kitchen with open to air and unsealed food-items available for resident use.
During an observation on 8/15/2022 at 10:33 AM, of the crumb tray under the grill, in the kitchen, with the DM revealed scattered brown food debris and a white powdered substance scattered throughout the crumb tray.
During an interview on 8/15/2022 at 10:35 AM, the DM stated the crumb tray should be cleaned every time the grill was used by the dietary staff. The DM confirmed the facility failed to maintain a sanitary kitchen with an unclean crumb tray containing food debris and a powdered substance.
During an observation on 8/15/2022 at 10:40 AM, of the metal shelf, at the food preparation table, in the kitchen, with the DM revealed:
-1 five-pound white bag of grits approximately ½ full open to air/unsealed, not placed in a container after opened, and available for resident use.
-1 one-pound box of light brown sugar approximately ¾ full open to air/unsealed, not placed in a container after opened, and available for resident use.
During an interview on 8/15/2022 at 10:45 AM, the DM stated the grits and brown sugar should have been placed in a container after opened by the dietary staff. The DM confirmed the facility failed to maintain a sanitary kitchen with food items opened to air/unsealed and not placed in a container after opened by the dietary staff.
During an observation on 8/15/2022 at 10:56 AM, of the walk-in freezer, in the kitchen, revealed one 5-pound bag of tater tots in a white plastic bag open to air/unsecured, undated when opened, and not dated with a use by date.
During an interview on 8/15/2022 at 11:00 AM, the DM confirmed the facility failed to maintain a sanitary kitchen with tater tots, open to air/unsecured, undated when opened, and undated with a use by date. The DM confirmed the food was available for resident use.
During an observation on 8/15/2022 at 11:02 AM, of the walk-in refrigerator, in the kitchen, revealed a 5-pound plastic bag of shredded lettuce approximately ½ full, open to air/unsealed, undated when opened, undated with a use by date, and available for resident use.
During an interview on 8/15/2022 at 11:02 AM, the DM confirmed the facility failed to maintain a sanitary kitchen with the shredded lettuce open to air/unsealed, undated when opened, undated with a use by date, and available for resident use.
Sept 2019
1 deficiency
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Observation and interview with the CDM on 9/17/19 at 3:41 PM, in the Unit 100 hallway nourishment room, revealed:
(1)- Chocolat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Observation and interview with the CDM on 9/17/19 at 3:41 PM, in the Unit 100 hallway nourishment room, revealed:
(1)- Chocolate Peanut Butter Silk Pie with ¼ of pie remaining in the refrigerator dated 9/15/19.
(1)- Butterfinger Pie with ¼ of pie remaining in the refrigerator dated 9/15/19.
The CDM confirmed the pies had been brought in by family members and had not been labeled with resident names.
Observation and interview with the CDM on 9/17/19 at 3:48 PM, in the Unit 200/300 hallway nourishment room, revealed:
(1)- 10 ounce jar of orange marmalade in the refrigerator opened and undated.
(1)- 32 ounce box of chicken broth in the refrigerator opened and undated.
(4)- 4 ounce cups of mandarin oranges in the refrigerator.
(1)- boxed frozen meal of [NAME] pasta with chicken and broccoli in the freezer.
(8)- 4.6 ounce cans of small hotdog sausages in the cabinet.
The CDM confirmed food items above were brought in by family/visitors and had not been labeled with resident name/room number and dated when opened.
Observation and interview with the CDM on 9/17/19 at 3:57 PM, on the 400 hallway nourishment room, revealed:
(1)- 8 fluid ounce bag of squeezable mayonnaise opened and undated.
The CDM confirmed the food item above had been brought in by family/visitors and had not been labeled with resident name/room number and dated when opened.
Observation and interview with the CDM on 9/17/29 at 4:00 PM, on the Unit 400 hallway nourishment room, revealed the ice chest machine with a blackish gray substance to the inside tray below the ice maker. The CDM confirmed the ice chest machine was dirty.
Observation and interview with the CDM on 9/17/19 at 4:07 PM, on the Unit 100 hallway nourishment room, revealed the ice chest machine with a blackish gray substance to the inside tray below the ice maker. The CDM confirmed the ice chest machine was dirty.
Interview with the Director of Nursing (DON) on 9/17/19 at 4:10 PM, in the DON's office, confirmed his expectation was for food to be labeled.
Based on review of the facility policy, observation, and interview, the facility failed to properly date and label frozen food items available for resident consumption for 1 of 3 Cottage kitchens, potentially affecting 29 of 30 residents; failed to maintain refrigerated food items in a sanitary manner in 3 of 3 nourishment rooms; and failed to maintain the sanitation of 2 of 3 ice machines, potentially affecting 115 of 116 residents.
The findings include:
Review of the facility policy Food Labeling and Dating Guidelines for Cold Storage, undated, revealed .Items must have a label stating the contents inside .foods that are removed from their original packaging should be labeled with the date it was received and expiration date or use by date .
Review of the facility policy Food Brought into Facility, dated 12/6/16, revealed .Outside foods requiring storage and refrigeration must be dated, labeled and stored per facility and state guidelines .
Review of the facility policy Personal Food Storage, dated 10/3/17, revealed .Food Brought in by outside sources will be monitored .All food and beverages brought in by outside sources will be labeled and dated .Food .in the original containers .unopened will be labeled with resident name and date received .
Review of the facility policy Ice Machine Policy, undated, revealed .Ice machine will be cleaned according to manufacturers recommendations quarterly this will be completed by maintenance department .
Observation with the Certified Dietary Manager (CDM) on 9/16/19 at 2:05 PM, of the [NAME] Cottage pantry freezer, revealed the following items had been removed from their original package and placed in ziplock bags:
4 individual pieces of 6 ounce of tilapia fillets, undated and unlabeled.
2 gallon-sized bags of beef fingers, undated and unlabeled.
1 gallon-sized bag of chicken breasts, unlabeled.
1 gallon-sized bag of catfish fillets, undated and unlabeled.
1 gallon-sized bag of hot dogs, undated and unlabeled.
1 gallon-sized bag containing a 4 pound meatloaf, unlabeled.
1 gallon-sized bag of [NAME] fillets, undated and unlabeled.
1 four pound bag of rope sausage, undated and unlabeled.
1 gallon-sized bag of Philly cheese steaks, undated and unlabeled.
1 gallon-sized bag of ham, undated and unlabeled.
1 gallon-sized bag of breaded pork chops, undated and unlabeled.
1 gallon-sized bag of drumsticks, undated.
1 three or 4 pound package of meatballs, opened.
Interview with the CDM on 9/16/19 at 2:25 PM, in the [NAME] Cottage pantry, confirmed, .It should all be dated and labeled .
Sept 2018
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, facility documentation review, and interview the facility failed to complete a th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, facility documentation review, and interview the facility failed to complete a thorough investigation for 1 resident (#247) of 26 residents reviewed for abuse of a total of 45 sampled residents.
The findings include:
Review of the facility policy Abuse, Neglect, Misappropriation Protocol revealed .The individual conducting the investigation will possibly include some or all of the following steps, depending upon the circumstances: .Interview the person(s) reporting the incident .witness reports will be reduced to writing. Witnesses will be required to sign and date such reports .
Medical record review revealed Resident #247 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Language Related Cognitive Disorder, and Alzheimer's disease.
Review of facility documentation dated 7/27/18 revealed .charge nurse reported that resident [Resident #247) was in altercation with another resident [Resident #248]. Residents wheel chairs became tangled up CNA [certified nursing assistant] separated residents Nurse reports that no contact was witnessed between residents nurse assessed resident [#247] from head to toe with no visible red marks, bruising, or scratches .
Interview with the Quality Assessment (QA) nurse on 9/19/18 at 7:48 AM, at the 300 hall nurse's desk, revealed the QA nurse was asked by the Director of Nursing (DON) to complete the investigation on 7/27/18 of the residents. Continued interview revealed the QA nurse was not told or aware initially of Resident #247 being struck by Resident #248 on 7/27/18. Interview revealed the facility became aware of the resident to resident contact between Resident #247and #248 when visited by local police department.
Interview with CNA #1 on 9/19/18 at 8:14 AM, by phone, revealed the CNA observed the two residents' wheelchairs tangled up, and observed Resident #248 hitting Resident #247 in the back 3 times. Continued interview revealed the residents were separated and the CNA reported to the Charge Nurse what had happened.
Interview with the Charge Nurse on 9/19/18 at 8:27 Am, by phone, revealed the Charge Nurse assessed both the residents with no visible marks, or bruising present. Continued interview revealed the Charge Nurse seperated the residents and reported the incident to the DON.
Interview with the Administrator and DON on 9/19/18 at 1:33 PM, in the Administrators office, revealed the Administrator and DON were informed of the incident and initially thought residents only got wheelchairs stuck together until visited by the local police department. Continued interview confirmed the facility failed to complete a thorough investigation, and failed to follow the facility policy for Abuse investigations.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of standards for nursing practice, facility policy review, medical record review, and interview, the facility fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of standards for nursing practice, facility policy review, medical record review, and interview, the facility failed to assess the vascular access for 1 resident (#54) of 2 residents who received dialysis of 45 residents sampled.
The findings include:
Review of Nursing Management (Springhouse): October 2010- Volume 41-Issue 10- pg 47 revealed .Caring for a patient's vascular access for hemodialysis .to protect and preserve the vascular access and avoid complications .Assess for patency [absence of blockage] at least every 8 hours .
Review of the facility policy for Post Dialysis Care revised 6/2018 revealed the post-hemodialysis nursing assessment includes .Assessment of dressing site for bleeding .Assessing dialysis catheter .dry and intact dress .
Medical record review revealed Resident #54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Respiratory Failure, End Stage Renal Disease, and Vascular Dementia.
Medical record review of the Quarterly Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 14 indicating the resident was cognitively intact. Further review revealed the resident received dialysis.
Medical record review of the care plan dated 1/1/17 revealed the resident required renal dialysis 3 times a week and had an AV (arteriovenous) shunt (access site for dialysis) in the right arm. Further review revealed .CHECK COLOR AND TEMP OF THE FINGERS AND PULSES ON THE ACCESS ARM FOR ADEQUATE CIRCULATION, AND MONITOR FOR S/S [signs and symptoms] OF INFECTION TO ACCESS SITE .MONITOR SHUNT FOR BLEEDING , AND DO NOT TAKE BLOOD PRESSURE IN THE ACCESS ARM
Medical record review revealed no documentation of assessment of the vascular access.
Interview with the Director of Nursing (DON) on 9/19/18 at 9:47 AM, in the conference room, confirmed the facility failed to monitor the vascular access for Resident #54.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Tennessee facilities.
- • 33% turnover. Below Tennessee's 48% average. Good staff retention means consistent care.
Concerns
- • 8 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
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About This Facility
What is Jefferson County's CMS Rating?
CMS assigns JEFFERSON COUNTY NURSING HOME an overall rating of 3 out of 5 stars, which is considered average nationally. Within Tennessee, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Jefferson County Staffed?
CMS rates JEFFERSON COUNTY NURSING HOME's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 33%, compared to the Tennessee average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Jefferson County?
State health inspectors documented 8 deficiencies at JEFFERSON COUNTY NURSING HOME during 2018 to 2022. These included: 2 that caused actual resident harm and 6 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Jefferson County?
JEFFERSON COUNTY NURSING HOME is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility operates independently rather than as part of a larger chain. With 160 certified beds and approximately 141 residents (about 88% occupancy), it is a mid-sized facility located in DANDRIDGE, Tennessee.
How Does Jefferson County Compare to Other Tennessee Nursing Homes?
Compared to the 100 nursing homes in Tennessee, JEFFERSON COUNTY NURSING HOME's overall rating (3 stars) is above the state average of 2.8, staff turnover (33%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Jefferson County?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Jefferson County Safe?
Based on CMS inspection data, JEFFERSON COUNTY NURSING HOME has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Tennessee. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Jefferson County Stick Around?
JEFFERSON COUNTY NURSING HOME has a staff turnover rate of 33%, which is about average for Tennessee nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Jefferson County Ever Fined?
JEFFERSON COUNTY NURSING HOME has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Jefferson County on Any Federal Watch List?
JEFFERSON COUNTY NURSING HOME is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.