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🔎 Collierville Nursing And Rehabilitation Llc

Inspection Results


Inspection Overview

Collierville Nursing And Rehabilitation Llc has been cited for a total of 38 deficiencies since we began saving each survey.

In Tennessee, the average facility has **18.90 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2022-12-09
Correction Date: 2022-12-29
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Provide timely, quality laboratory services/tests to meet the needs of residents.

Survey Date: 2022-12-09
Correction Date: 2022-12-29
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2022-11-29
Correction Date: 2022-12-16
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2022-08-17
Correction Date: 2022-09-17
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2022-08-17
Correction Date: 2022-09-17
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2022-08-17
Correction Date: 2022-09-17
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: E

Post nurse staffing information every day.

Survey Date: 2022-08-17
Correction Date: 2022-09-17
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2022-08-17
Correction Date: 2022-09-17
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2022-02-25
Correction Date: 2022-04-01
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2022-02-25
Correction Date: 2022-04-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2022-02-25
Correction Date: 2022-04-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2022-02-25
Correction Date: 2022-04-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2022-02-25
Correction Date: 2022-04-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2022-02-25
Correction Date: 2022-04-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide or obtain dental services for each resident.

Survey Date: 2022-02-25
Correction Date: 2022-04-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2022-02-25
Correction Date: 2022-04-01
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: K

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

Survey Date: 2021-09-18
Correction Date: 2021-10-13
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: K

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Survey Date: 2021-09-18
Correction Date: 2021-10-13
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: K

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

Survey Date: 2021-09-18
Correction Date: 2021-10-13
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: K

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

Survey Date: 2021-09-18
Correction Date: 2021-10-13
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2021-04-09
Correction Date: 2021-05-08
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Survey Date: 2019-12-11
Correction Date: 2020-01-04
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Survey Date: 2019-12-11
Correction Date: 2020-01-04
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2019-12-11
Correction Date: 2020-01-04
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-12-11
Correction Date: 2020-01-04
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2019-12-11
Correction Date: 2020-01-04
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2019-12-11
Correction Date: 2020-01-04
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2019-12-11
Correction Date: 2020-01-04
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Survey Date: 2019-12-11
Correction Date: 2020-01-04
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-12-11
Correction Date: 2020-01-04
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2019-12-11
Correction Date: 2020-01-04
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2019-12-11
Correction Date: 2020-01-04
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2019-12-11
Correction Date: 2020-01-04
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2019-12-11
Correction Date: 2020-01-04
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Provide care by qualified persons according to each resident's written plan of care.

Survey Date: 2019-02-06
Correction Date: 2019-03-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2019-02-06
Correction Date: 2019-03-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2019-02-06
Correction Date: 2019-03-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2019-02-06
Correction Date: 2019-03-15
Category: Nutrition and Dietary Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**