Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391

Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 883826 (X3) Date Survey Completed 03/03/2026
Name of Provider or Supplier Decaturville Family Practice Street Address, City, State 187 West Main Street, Decaturville, TN
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
E0000 An unannounced Emergency Preparedness Survey was initiated at the facility in conjunction with a recertification survey on 03/03/2026 at 9:10 AM. An Entrance Conference was held with the Administrator/Owner on 03/03/2026 at 9:20 AM. The purpose of the survey was explained. Requests were made. An opportunity to ask questions/provide comments was provided. An Exit Conference was held with the Administrator/Owner at the facility on 03/03/2026 at 2:00 PM. The Administrator/Owner was notified of preliminary findings of deficiency under E0001 - Emergency Prepardness.