D62

ASCENSION LIVING ALEXIAN VILLAGE TENNESSEE

Grade D 62/100 composite score

Non profit - Corporation

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
3/5
Staffing
4/5
RN Staffing
Not rated

Certified Beds

114

Ownership

Non profit - Corporation

Total Fines

$214,408

Last Survey

N/A

671 ALEXIAN WAY, SIGNAL MOUNTAIN, TN 37377
4238860100

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.72h
LPN
1.38h
CNA
2.29h
Total
4.40h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

ASCENSION HEALTH SENIOR CARE

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Jan 2018

MUSGRAVE, LISA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Sep 2023

BINEK, ROBIN

IndividualCORPORATE DIRECTORSince Jan 2024

BREEDLOVE, RYAN

IndividualCORPORATE DIRECTORSince Jan 2024

GRONEFELD, KELLIE

IndividualCORPORATE DIRECTORSince Aug 2023

SHADBOLT, ERIN

IndividualCORPORATE DIRECTORSince Jan 2024

SMOOT, KENNETH

IndividualCORPORATE DIRECTORSince Jan 2024

MILLER, AARON

IndividualW-2 MANAGING EMPLOYEESince Mar 2024

Penalties & Fines (2)

$214,408total fines
DateTypeDescriptionAmount
Oct 11, 2023Fine$214,408
Oct 11, 2023Payment Denial

Health Inspection Deficiencies (27)

September 25, 2024Health3 deficiencies
0584DMinimal harm, Isolated

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Rights Deficiencies

Corrected Oct 12, 2024
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 12, 2024
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Oct 12, 2024
August 7, 2024Health3 deficiencies
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Sep 1, 2024
0756DMinimal harm, Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Corrected Sep 1, 2024
0842DMinimal harm, Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Sep 1, 2024
December 13, 2023Health3 deficiencies
0609EMinimal harm, Pattern

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jan 12, 2024
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jan 12, 2024
0867DMinimal harm, Isolated

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Administration Deficiencies

Corrected Jan 12, 2024
October 11, 2023Health10 deficiencies5 severe
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Nov 21, 2023
0602EMinimal harm, Pattern

Protect each resident from the wrongful use of the resident's belongings or money.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 21, 2023
0657JImmediate jeopardy, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 21, 2023
0658JImmediate jeopardy, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 21, 2023
0684JImmediate jeopardy, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Nov 21, 2023
0689JImmediate jeopardy, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Nov 21, 2023
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Nov 21, 2023
0700FMinimal harm, Widespread

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.

Quality of Life and Care Deficiencies

Corrected Nov 21, 2023
0835JImmediate jeopardy, Isolated

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Administration Deficiencies

Corrected Nov 21, 2023
0842FMinimal harm, Widespread

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 21, 2023
November 20, 2019Health1 deficiency
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Dec 20, 2019
November 7, 2018Health7 deficiencies
0561DMinimal harm, Isolated

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Corrected Dec 14, 2018
0644DMinimal harm, Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 14, 2018
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 14, 2018
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Dec 14, 2018
0756DMinimal harm, Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Corrected Dec 14, 2018
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Dec 14, 2018
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Dec 14, 2018

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Frequently Asked Questions

What is the CareGrader rating for ASCENSION LIVING ALEXIAN VILLAGE TENNESSEE?

ASCENSION LIVING ALEXIAN VILLAGE TENNESSEE in SIGNAL MOUNTAIN, Tennessee has a CareGrader grade of D (Below Average), with a composite score of 62.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for ASCENSION LIVING ALEXIAN VILLAGE TENNESSEE?

ASCENSION LIVING ALEXIAN VILLAGE TENNESSEE has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 4/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does ASCENSION LIVING ALEXIAN VILLAGE TENNESSEE have?

ASCENSION LIVING ALEXIAN VILLAGE TENNESSEE has 27 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has ASCENSION LIVING ALEXIAN VILLAGE TENNESSEE been fined?

Yes. ASCENSION LIVING ALEXIAN VILLAGE TENNESSEE has $214,408 in total fines from CMS enforcement actions across 2 penalties.

How many beds does ASCENSION LIVING ALEXIAN VILLAGE TENNESSEE have?

ASCENSION LIVING ALEXIAN VILLAGE TENNESSEE has 114 certified beds with approximately 82 current residents (72% occupancy). The facility is located at 671 ALEXIAN WAY, SIGNAL MOUNTAIN, Tennessee 37377. It is a non profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.