Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Antioch Tn Opco, Llc during CMS and state inspections, most recent first.
A resident with a documented history of ingesting non-food items was admitted without a care plan or staff awareness of her behaviors. Over several days, she reported difficulty swallowing and chest pain, but was not sent to the hospital until her family intervened. Medical records showed prior evidence of foreign bodies in her stomach that were not addressed. Upon hospital transfer, multiple objects were found in her digestive tract, leading to severe injury and death. Staff interviews revealed a lack of communication and failure to implement required monitoring and care planning.
A resident with moderate cognitive impairment reported being sexually assaulted by a male staff member matching the description of an agency employee. Despite the report and supporting details, facility leadership did not conduct a thorough investigation, failed to interview all involved parties or assess other residents, and did not document the process as required, resulting in Immediate Jeopardy and substandard quality of care.
A resident with severe cognitive impairment and known exit-seeking behaviors eloped from the facility through a window that lacked a safety stop, remaining missing for an extended period before being found miles away. The resident's care plan was not updated after repeated exit-seeking incidents, and staff failed to provide adequate monitoring or conduct regular safety checks, particularly during overnight shifts. The facility also had a history of complaints about staff not providing care or responding to call lights at night, and management did not provide sufficient oversight or auditing during these hours.
Failure to Address and Monitor Resident's Ingestion of Non-Food Items Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not providing the necessary structure and processes to meet her care needs, specifically regarding her known behavior of ingesting non-food items. The resident was admitted from a behavioral health hospital with a documented history of eating non-food items, including objects large enough to pose suffocation hazards. Despite this, the facility did not develop a person-centered care plan to address or monitor for these behaviors, and staff were not made aware of her behavioral history. Multiple staff members, including nurses, therapists, and the psychologist, confirmed they were unaware of the resident's history of ingesting non-food items, and this information was not discussed in care plan or interdisciplinary team meetings. The resident began to complain of difficulty swallowing, sore throat, and chest pain over an eight-day period, but was not transferred to the hospital until her husband intervened. During this time, her complaints were documented in progress notes, and she experienced significant weight loss. A CT scan performed months earlier had revealed foreign bodies in her stomach, but this finding was not followed up or addressed in her care plan. The medical director and attending physician both acknowledged that the presence of foreign bodies should have triggered evaluation and monitoring, but no such actions were taken. The lack of communication and follow-up on critical medical information contributed to the failure to provide appropriate supervision and a safe environment for the resident. Upon eventual transfer to the hospital, multiple non-food items were found in the resident's digestive tract, including a spoon, straws, a toothbrush, and other objects, resulting in severe injury and ultimately her death. Interviews with facility staff revealed systemic failures in reviewing and communicating behavioral and medical histories during admission and ongoing care. The facility's policies required identification, assessment, care planning, and monitoring of residents with behaviors that could lead to neglect, but these were not implemented for this resident, leading to Immediate Jeopardy and substandard quality of care.
Removal Plan
- Staff who were not available during the training will be trained before being allowed to work.
- Staff must attain a 100% score on training and be retrained by the DON, VP of Clinical Services, SDC, or Unit Manager if the score is less than 100%.
- The DON, VP of Clinical Services, SDC, and Unit Manager reviewed the current residents' assessed history of pertinent/related behaviors.
- All potential admissions/patient referrals were reviewed by the admission director, DON/Unit Manager/MDS Nurse prior to admission to the facility.
- If any relevant behavior is identified, a care plan will be developed upon admission to address the behavior identified.
- The DON will follow-up pertinent radiology results within 24 hours. In the absence of the DON, the ADON will follow-up radiology results.
- Radiology results will be relayed to the attending physician; a care plan will be developed to address the radiology results as needed.
- The DON conducted a huddle meeting with the nursing staff to identify any resident who may have similar behavior like Resident #2.
- The clinical leadership team completed a screening of all residents for aggressive behavior and screening for risk for abuse of all residents.
- Identified concerns from the completed screenings were care planned by the clinical leadership team.
- The DON, UM, SSD, and SDC conducted resident abuse interviews or skin assessments. Residents who are able to participate were interviewed to ensure that they feel safe in the facility. The results of the interviews will be documented in the Resident Abuse Interview. Residents unable to participate due to cognitive deficit were assessed by nurses to identify signs of abuse/neglect.
- Ad-Hoc QAPI meeting was completed with the leadership team to discuss the incident and systemic changes to prevent recurrence.
- Review of potential admissions (referrals) by the admission staff, DON or her designee prior to admissions.
- Development of care plan upon admission to address any identified risk from review of documents, such as hospital records and other documents which provided information about the potential admissions medical and psychiatric history.
- Care plan review of all current residents to ensure that any identified behaviors are addressed with person-centered interventions.
- The DON will review the clinical huddle meeting records daily to identify any concern related to resident's behavior to ensure that the behaviors are care planned with person-centered interventions.
- The clinical leadership team reviewed all care plans of current residents to ensure that all behaviors are care planned with person-centered interventions.
Failure to Investigate Sexual Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of sexual abuse made by a resident. The resident, who had moderate cognitive impairment and was dependent on staff for care, reported being sexually assaulted by a male staff member matching the description of an agency employee. The incident was reported to facility leadership, and the staff member in question was identified as having worked in the area during the relevant time period. Despite the resident's detailed account and the staff member's presence in the facility, the facility did not complete a comprehensive investigation. Interviews and record reviews revealed that the facility did not interview all potentially involved parties, including other residents who may have been affected, nor did they thoroughly document the investigation process. The facility's leadership relied on inconsistencies in the resident's account and the belief that the alleged perpetrator was not present at the time of the incident as reasons not to pursue a full investigation. No further assessment of other residents or follow-up interviews were conducted after the resident was transferred to the hospital. Key staff members, including the Administrator, Medical Director, and Social Services Director, confirmed that no comprehensive investigation took place. The staffing agency was not notified of the incident, and there was no evidence of a root cause analysis or efforts to determine if other residents were at risk. The lack of a thorough investigation and failure to follow facility policy and regulatory requirements resulted in a finding of Immediate Jeopardy and substandard quality of care.
Removal Plan
- Staff who were not available during the training will be trained before being allowed to work, and must attain a 100% score on competency verification; retraining will be provided if the score is less than 100%.
- Staff provided with education/re-education & competency verification on sexual abuse and evidence protection.
- Any concerns identified during staff interviews will be addressed by the DON/Administrator.
- Facility actions include providing additional training, conducting additional interviews as part of the investigation, conducting root cause analysis of any concern identified, and reporting to QAPI committee any patterns and trends identified.
- The QAPI team developed an abuse/neglect quality assurance tool to review all incidents and allegations of abuse/neglect.
- QAPI team review of all allegations and incidents to ensure thorough investigation, immediate removal of alleged perpetrator, prompt reporting to Administrator and state agency, notification of law enforcement, adherence to abuse/neglect protocol, and implementation of interventions to ensure resident protection.
- QAPI team will discuss patterns/trends during Ad-Hoc and scheduled monthly QAPI meetings, including members of the governing body and executive management team when investigating any allegation of abuse/neglect.
- Residents able to participate were interviewed to ensure they feel safe; results documented in Resident Abuse Interview. Residents unable to participate were assessed by nurses for signs of abuse/neglect.
- Ad-Hoc QAPI meeting with leadership team to discuss the deficiency and corrective actions.
- Policies and procedures related to investigation of allegations of abuse/neglect were reviewed by leadership; no revision needed.
- Leadership team provided with training by Regional Regulatory Compliance Officer regarding investigation process, resident protection, and compliance monitoring.
- Significant Event Call (SEC) process implemented for review of abuse/neglect allegations, including participation by facility leadership and executive management.
- Staff provided with training on responsibility to participate/cooperate in investigations, abuse policy, and prevention of resident abuse/neglect; posttests requiring 100% score.
- Agency staff, if used in the future, will receive the same training and competency verification as facility staff.
- DON/NHA and IDT will conduct daily clinical meetings to discuss residents with new or worsening behavior/cognition and ensure care plans are developed and concerns addressed immediately.
- DON/NHA/Charge nurse/MOD will review residents with worsening behavior/cognition to ensure care plans and immediate action.
- DON/Administrator will review/audit all incidents/potential abuse daily to ensure compliance with investigation of allegations of abuse.
- Ad-Hoc QAPI meetings to review results of observations and monitoring activities related to prevention of elopement and abuse, with follow-up on concerns and additional interventions as needed, for a minimum of three months.
- Monthly QAPI meetings to discuss facility actions related to investigation of abuse/neglect, determine need for additional interventions or corrective actions, and review results of monitoring activities.
Failure to Prevent Elopement Due to Inadequate Supervision and Environmental Safety
Penalty
Summary
A facility failed to ensure a safe environment and provide adequate supervision to prevent the elopement of a severely cognitively impaired resident with known exit-seeking behaviors. The resident, who was dependent on staff for toileting hygiene, lower body dressing, and required supervision for eating, left the facility through a window in his room. The facility was unaware of the resident's absence for an undetermined length of time, with the last known sighting at approximately 10:30 PM and the resident being found 18 hours later, 5.1 miles away beside a busy street. The window in the resident's room was found open with the screen pushed out, and the window stop, which should have prevented the window from opening fully, was missing. Staff had not been checking windows as part of their routine safety checks prior to the incident. The resident had a documented history of wandering and exit-seeking, including removing his Wander Guard device and making statements about wanting to leave. Despite these behaviors, the care plan was not revised after actual exit-seeking incidents, and interventions were not updated to address the resident's ability to remove safety devices or to increase monitoring. Video footage confirmed that no staff entered the resident's room for several hours overnight, and the resident's bed was undisturbed, indicating a lack of monitoring. Staff interviews revealed inconsistent rounding practices, with some staff only entering rooms if residents were incontinent, and there was no documentation of increased monitoring for high-risk residents. Additionally, the facility had a pattern of complaints regarding staff not providing care or answering call lights during the overnight shift, with 22 complaints logged over 15 months. Disciplinary records for staff included failures to provide care and respond to resident needs during the night shift. Management was aware of these issues but did not conduct audits or provide oversight during the critical overnight hours. The lack of supervision, failure to implement and update care plan interventions, and inadequate environmental safety checks directly contributed to the resident's elopement and the resulting Immediate Jeopardy finding.
Removal Plan
- Staff who were not available during the training will be trained before being allowed to work, and must attain a 100% score on post-training tests; retraining provided if less than 100%.
- Staff were provided education/re-education on frequency of monitoring residents, especially those with wandering and exit seeking behaviors, including notification procedures and enhanced supervision protocols.
- Residents identified as high risk for elopement are added to the Elopement Binder and discussed in staff huddle meetings.
- High risk for elopement residents are monitored by nurses and nursing assistants; DON and clinical managers conduct daily unit rounds, and Nurse Supervisor/MOD on weekends.
- Residents at high risk for elopement are reviewed during daily clinical meetings and weekend clinical meetings by MOD/Nurse Supervisor.
- Elopement risk reassessments were completed for all residents by DON, unit manager, MDS nurse, and VP of Clinical Services.
- Care plans for residents identified as high risk for elopement were reviewed and updated by DON, unit manager, MDS nurse, and VP of Clinical Services.
- Ad-Hoc QAPI meeting was completed with leadership and clinical team to discuss the incident and facility actions.
- Elopement drills were conducted and will continue daily for 7 days, weekly for 3 months, then monthly.
- Signs were posted on lobby doors asking visitors not to assist residents outside the door.
- All doors and windows in the facility were checked for security and function; exit stopper door alarms checked for proper function.
- If door/window checks reveal a problem, Maintenance Director/Staff will notify Administrator/DON and assign staff to monitor until fixed.
- Daily checks of doors and windows for 3 months, including weekends, by Maintenance Director/Staff/Administrator/MOD/Charge Nurse; QAPI team to review after 3 months for frequency adjustment.
- Policies related to exit-seeking behaviors, elopement and wandering care plan, missing resident, responding to alarms, and resident safety and supervision were reviewed.
- Staff were provided training on exit-seeking behaviors, elopement and wandering care plan, missing resident, redirecting residents, responding to alarms, and resident safety and supervision; posttests required 100% score.
- Agency staff, if used, will receive the same training and posttest requirements as facility staff.
- DON, SDC, and Unit Manager will monitor nursing documentation and conduct unit observation rounds to identify new or worsening exit seeking/wandering behaviors and ensure care plans are followed.
- During weekends, Nurse Supervisor and/or MOD will review documentation and conduct unit observations for exit seeking/wandering behaviors and care plan compliance.
- Any concerns identified during monitoring will be addressed immediately, with notification to DON or Administrator and implementation of additional interventions as needed.
- New admissions and re-admissions will be reviewed for elopement risk by SSD, DON, Unit Manager, SDC, or MDS Nurse; appropriate care plan interventions and elopement book updates will be ensured.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 81 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Antioch
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Hickory Woods | 3.6 mi | ★★★★★ | 6 | 0 |
| Bethany Center For Rehabilitation And Healing Llc | 3.9 mi | ★★★★★ | 0 | 0 |
| Trevecca Center For Rehabilitation And Healing Llc | 8.6 mi | ★★★★★ | 0 | 0 |
| Somerfield At The Heritage | 8.6 mi | ★★★★★ | 0 | 0 |
| Smyrna Care Center | 9.2 mi | ★★★★★ | 1 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.