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 883843 (X3) Date Survey Completed 05/13/2026
Name of Provider or Supplier Dickson Medical Associates Mathis Pediatrics Street Address, City, State 110 Mathis Drive, Suite 103, Dickson, 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 Center for Disease Control and Prevention (CDC) Guidelines, policy review, observation, and interview, the facility failed to maintain infection control for 1 of 6 (Patient #2) patients observed. The findings included: Review of the Center for Disease Control and Prevention (CDC) Guidelines titled "Environmental Cleaning Procedures," dated 03/19/2024, revealed shared noncritical patient care equipment (such as a stethoscope) should be cleaned and disinfected with chlorine/ hypochlorite or 60-80 % alcohol before and after each use. Review of the facility's document titled "Emerging Infectious Diseases," undated, revealed all non-dedicated, non-disposable equipment used for patient care should be cleaned and disinfected according to the manufacturer ' s instructions and facility policy. The policy did not address when or how often noncritical equipment such as a stethoscope should be disinfected. Observations in the patient examination rooms on 05/13/2026 at 8:50 AM, revealed Advanced Practical Registered Nurse (APRN) #1 entered Patient #1's room and auscultated (listened to internal sounds of the body) Patient #1's chest with a stethoscope. At 9:04 AM, APRN #1 entered Patient #2's room and auscultated Patient #2's chest with the same stethoscope. APRN #1 did not disinfect the stethoscope between Patient #1 and #2. During an interview on 05/13/2026 at 10:55 AM, Medical Doctor (MD) #1 stated that staff were to disinfect their stethoscopes between patients using germicidal disposable wipes.