Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Andersonville Tn Opco Llc during CMS and state inspections, most recent first.
The facility failed to notify a resident's responsible party/conservator of a significant change in condition. A resident with dementia, protein-calorie malnutrition, and adult failure to thrive had severe cognitive impairment, significant weight loss, and a low BMI, but there was no documentation that the representative was informed. The responsible party said he was not notified, and the DON confirmed the lack of documentation.
Failure to update fall care plan after a resident fall. A resident with dementia, osteoporosis, and severe cognitive impairment fell while going to the bathroom unassisted and slipping from a wheelchair onto the right hip. The incident report listed new interventions of non-skid footwear and a bowel training program, but the comprehensive care plan still only identified fall risk related to weakness and was not revised to include the new interventions. The MDS Coordinator and DON both confirmed the care plan had not been updated.
Failure to Follow Hand Hygiene and Droplet Precautions: CNA A and CNA B entered a room on Droplet Precautions for a COVID-positive resident without goggles or a face shield, and a restorative CNA entered the same room without gloves, gown, mask, or goggles. In a separate event, a CNA provided direct care to two residents and repeatedly failed to wash or sanitize hands after exiting and re-entering resident rooms, including after incontinence care, a transfer, and turning off a call light; the DON confirmed the infection control failures.
The facility failed to maintain a homelike environment in certain rooms, with missing blind slats and openings in heating and cooling units compromising safety and comfort. The Administrator, DON, and Maintenance Director confirmed these deficiencies, indicating a lapse in adhering to the facility's policy on maintaining a safe and comfortable environment.
Failure to Notify Representative of Significant Weight Loss
Penalty
Summary
The facility failed to notify a resident representative of a significant change in condition for Resident #16. Facility policy required notification of the resident or resident representative for changes in condition or status, including significant deterioration in health and significant changes in weight or intake. Resident #16 was admitted and later readmitted with diagnoses including dementia, protein-calorie malnutrition, and adult failure to thrive. The quarterly MDS showed a BIMS score of 03, indicating severe cognitive impairment, and the resident also had weight loss. A dietician progress note dated 8/2/2025 documented significant weight loss of 8.3% over 30 days and 11.7% over 90 days, with a BMI of 17.3 and underweight status. The care plan was revised on 8/8/2025 to reflect unplanned weight loss related to poor food intake. However, there was no documentation that the resident's responsible party/conservator was notified of the significant weight loss. During interview, the responsible party stated he was not notified, and the DON confirmed there was no documentation that notification had occurred.
Failure to Update Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise Resident #16’s comprehensive care plan to include a new fall intervention after the resident experienced a fall. Resident #16 was admitted and later readmitted with diagnoses including Dementia, Osteoporosis, and Adult Failure to Thrive. The quarterly MDS assessment showed a BIMS score of 03, indicating severe cognitive impairment, and noted no falls since admission. A fall incident report dated 11/19/2025 documented that the resident was going to the bathroom unassisted and slipped from a wheelchair onto the right hip, with new interventions listed as non-skid footwear and a bowel training program. Review of the comprehensive care plan dated 11/29/2025 showed the resident was at risk for falls related to weakness, but no new intervention had been added after the 11/19/2025 fall. The facility’s policy required the care plan to be reviewed and updated as indicated after any resident fall. During interviews, the MDS Coordinator confirmed the care plan had not been revised to include the new intervention after the fall, and the DON also confirmed the comprehensive care plan had not been revised to include nonskid footwear and a toileting program after the fall.
Failure to Follow Hand Hygiene and Droplet Precautions
Penalty
Summary
The facility failed to follow infection control practices on 2 of 4 hallways observed, based on policy review, observations, and interviews. The facility policy on Hand Hygiene stated that all staff will perform proper hand hygiene to prevent the spread of infection to residents and that hand hygiene includes washing with soap and water or using an alcohol-based hand rub when indicated. The Isolation Precautions guidelines stated that droplet precautions are designed to reduce or prevent transmission of pathogens spread through close respiratory contact with respiratory secretions, and that healthcare personnel will wear a facemask for close contact with an infectious resident if there is a risk of exposure, with gloves, gown, and goggles or face shield also to be worn. During an observation, CNA A and CNA B entered a room posted for Droplet Precautions for a resident who was COVID positive, but they did not don goggles or a face shield before entering. During another observation, Restorative CNA C entered the same Droplet Precautions room without donning gloves, gown, mask, or goggles, and confirmed the omission. In a separate observation, CNA D entered resident rooms, provided incontinence care to one resident and transferred another resident from a wheelchair to a bed, then repeatedly exited and re-entered rooms without washing or sanitizing hands, including after turning off a call light. CNA D confirmed he failed to wash or sanitize his hands after providing direct care in rooms 200B and 207B. The DON confirmed that CNA A, CNA B, Restorative CNA C, and CNA D had not followed infection control practices.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment in specific rooms on the 100 and 400 halls. Observations revealed that the vertical blinds in one room were missing slats, compromising privacy and comfort. Additionally, there were small openings visible to the outside at the upper corners of the heating and cooling units in multiple rooms, which could affect the safety and comfort of the residents. Interviews with the Administrator, Director of Nursing (DON), and the Maintenance Director confirmed these deficiencies. They acknowledged the presence of the openings in the heating and cooling units and the missing blind slats, indicating a failure to provide an optimal homelike environment for the residents. The facility's policy on maintaining a safe and comfortable environment was not adhered to, as preventive maintenance schedules were not effectively followed, and issues with furnishings were not promptly reported or addressed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Andersonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rocky Top Care Center | 5.7 mi | ★★★★★ | 7 | 0 |
| The Waters Of Clinton, Llc | 6 mi | ★★★★★ | 7 | 0 |
| Tennova Lafollette Health And Rehab Center | 10.3 mi | ★★★★★ | 0 | 0 |
| Beverly Park Place Health And Rehab | 12.4 mi | ★★★★★ | 0 | 0 |
| Cumberland Village Care | 12.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.