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 883829 (X3) Date Survey Completed 02/09/2026
Name of Provider or Supplier Humboldt Family Walk-In Clinic Llc Street Address, City, State 1600 Coleman Drive, Humboldt, 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)
J0044 PHYSICAL PLANT AND ENVIRONMENT

The clinic . . . has a preventive maintenance program to ensure that: 491.6(b)(3) The premises are clean and orderly.


This STANDARD is not met as evidenced by:
Based on review of the facility's policy and observations, the facility failed to ensure the Rural Health Clinic (RHC) utilized preventive measures to prevent the spread of infectious disease to 4 of 4 patients (Patients #1, #2, #3 and #4). The findings included: Review of the facility's policy, "Infectious Control Policy", dated 2/10/2026, revealed the facility failed to provide documentation of a preventive maintenance program that provided measures to prevent the spread of infectious diseases. Observation on 2/9/2026, at 10:20 AM, revealed that Advanced Practice Registered Nurse (APRN; who was shadowed by Student Nurse) listened to Patient #1's lung sounds. The APRN failed to perform hand hygiene upon entering the room and after the visit. The APRN handled documents and proceeded to enter next patient's room. Observation on 2/9/2026, at 10:30 AM, revealed the APRN failed to perform hand hygiene and don a mask prior to entering Patient #2's room. Patient #2 complaining of a sore throat and fever days prior to the visit. The APRN and the Student Nurse entered the room without a mask or gloves. The APRN looked at Patient #2's throat. There was no observation the APRN performed hand hygiene after Patient #2's visit. After exiting Patient #2's room, the APRN handled documents and touched objects at the nurses' station prior to entering Patient #3's room. Observation on 2/9/2026, at 10:35 AM, revealed the APRN, accompanied by an interpreter, entered Patient #3's room without performing hand hygiene upon entering and during the office visit. The APRN donned gloves to touch a "boil on leg" of Patient #3. The APRN touched the affected area, removed the gloves, discarded them, and put on another pair prior to looking at another. Observation on 2/9/2026, at 11:25 AM, revealed the APRN failed to perform hand hygiene upon entering and after Patient #4's visit.