Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ascension Living Alexian Village Tennessee during CMS and state inspections, most recent first.
A nurse administered medications intended for another resident to a cognitively intact individual with multiple chronic conditions, failing to verify identity or medication details as required by policy. The error was not recognized until the resident developed severe hypotension and required hospitalization. The incident was caused by distraction and failure to follow established medication administration protocols.
An LPN stood while assisting a resident with lunch and referred to residents who need help eating as "feeders." The resident had a hx of stroke with hemiplegia, aphasia, and AFib, and an MDS showed severely impaired cognitive skills and substantial to maximal assistance with eating. The RN/DQM stated this did not maintain dignity and that staff were expected to sit at the resident's eye level during meals.
Call Light Not Within Reach: A resident with severe cognitive impairment and diagnoses including CAD, HTN, Parkinsons, and depression was observed multiple times lying in bed with the call light hanging over the headboard and out of reach. The resident stated she pushed a button when she needed help, and an LPN confirmed the call light was not within reach; CNAs and the DON stated the resident was able to activate it and expected it to be in reach at all times.
Failure to follow and update orthotic care plans: one resident with a new R distal fibula fracture and order for a tall walking boot was observed in bed without the boot despite the care plan stating it should be worn at all times, and another resident with L arm/hand contractures repeatedly refused a L wrist/hand splint, with refusals documented on the TAR but not in the care plan or nurse's notes.
Incomplete meal intake documentation and missed nutritional supplement administration: A resident with dysphagia and risk for unintended weight loss had an order for Jevity if meals were eaten at 50% or less. Staff documented several meals only as 25-50% without specifying whether the intake met the order criteria, left multiple meals undocumented, and signed the TAR as N-Treatment Not Administered for all supplement doses without any reason documented in the TAR or nursing notes.
Insufficient nursing staff on a high-acuity hallway led to delayed response to call lights and unmet resident care needs. The hallway had multiple residents requiring 2-person transfers, Hoyer lift use, and extensive or total assistance with ADLs, while staff reported only 2 CNAs and 1 nurse on day shift. A resident’s call light went unanswered for 20 minutes and was not answered until 29 minutes later, and staff, the DON, and the Administrator acknowledged that call lights were not always answered timely because the resident needs exceeded the available CNA coverage.
Controlled medication reconciliation was not completed for 3 residents. During review of the medication cart, the narcotic counts for oxyCODONE and traMADol did not match the controlled drug records for three residents. An RN stated one dose had been refused and needed to be wasted, and for two other residents she had administered the doses and documented them in the computer but had not yet signed them out in the narcotic book. The DON confirmed narcotics should be signed out on the narcotic reconciliation sheet as soon as they are administered.
Failure to Offer Hand Hygiene Assistance Before Meal Service: A CNA failed to offer hand hygiene assistance to a resident before lunch meal service. The resident had hemiplegia, severe cognitive impairment, and required assistance with personal care, eating, and hygiene. The CNA set up the meal tray and the resident began eating without hand hygiene assistance, despite facility policy stating residents should be encouraged, reminded, and/or assisted with hand hygiene before meals.
The facility failed to maintain a homelike environment for two residents. One resident with moderate cognitive impairment was in a room with a damaged baseboard and gouges in the wall, covered with tape. Another resident with severe cognitive impairment was in a room with tears in the paint and drywall. The administrator confirmed the need for repairs.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with indwelling urinary devices. Despite having suprapubic or indwelling catheters, the care plans did not include EBP, and there was no signage or PPE available. Interviews with staff, including an LPN and CNAs, revealed a lack of awareness and implementation of EBP requirements, as they only wore gloves during catheter care.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling devices, as required by their infection control policy. Observations and interviews revealed that staff were not using gowns and gloves during high-contact activities for residents with catheters. Residents and staff were unaware of the need for EBP, and there was no signage or PPE available, indicating a systemic failure to adhere to infection control protocols.
A facility failed to accurately complete an MDS assessment for a resident with multiple diagnoses, including COPD and Vascular Dementia. Despite a fall incident on December 27, 2023, which required emergency evaluation, the quarterly MDS assessment dated January 25, 2024, did not document any falls. The Interim MDS Coordinator confirmed the inaccuracy during an interview.
A facility failed to remove discontinued narcotics from inventory, leading to discrepancies in medication documentation for a resident with severe cognitive impairment. Despite the discontinuation of Percocet, it was documented as withdrawn by an RN without administration records. The resident did not report pain or request medication, and the RN did not respond to investigation attempts, suggesting potential diversion.
A resident with a history of falls experienced an unwitnessed fall that was not documented in their medical record, contrary to facility policy. The fall was discovered after an Environmental Services employee reported a new skin injury, leading to an investigation. The responsible agency nurse failed to document the incident, resulting in their termination.
Medication Error Resulting in Severe Hypotension and Hospitalization
Penalty
Summary
A significant medication error occurred when a registered nurse (RN) administered medications intended for another resident to a cognitively intact resident who required supervision with activities of daily living. The nurse failed to verify the resident's identity and did not check the medication labels for the correct resident, medication, dosage, time, or route of administration prior to giving the medications. This action was in direct violation of the facility's medication administration policy, which requires verification of the 'five rights' before administering any medication. The error was not identified at the time of administration or during subsequent documentation. Approximately two hours after receiving the incorrect medications, the resident developed symptoms including dizziness and lightheadedness, and questioned the nurse about the medications received. Upon review, it was discovered that the resident had been given a combination of medications including antihypertensives and other drugs, which were not prescribed for him. This led to severe hypotension, with blood pressure readings dropping to critically low levels, necessitating emergency medical intervention and hospitalization. The resident's medical history included hemiplegia, atrial fibrillation, hypertensive chronic kidney disease, hypertension, and anemia. The administration of the wrong medications resulted in harm, specifically severe hypotension and hospitalization. The incident was attributed to the nurse being distracted while preparing medications and not following established clinical standards and facility policy for safe medication administration.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to ensure staff promoted resident dignity during dining for one resident who required substantial to maximal assistance with eating. The resident was admitted with diagnoses including history of stroke with hemiplegia, aphasia, and atrial fibrillation, and a quarterly MDS assessment showed severely impaired cognitive skills for daily decision making. During a lunch observation, an LPN was standing while assisting the resident with the meal in the dining room. During interview, the LPN stated that she usually stands up when feeding a resident because she gets antsy sitting too long and said the facility had several "feeders," referring to residents who require assistance to eat. The RN/DQM later stated that standing while assisting the resident to eat and referring to residents who required assistance with eating as feeders did not maintain resident dignity, and confirmed staff were expected to sit at the resident's eye level when assisting residents during dining and should not refer to residents as feeders.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure the call light was within reach for Resident #41, who was admitted with diagnoses including anemia, coronary artery disease, hypertension, Parkinsons, and depression. The resident’s comprehensive care plan identified impaired communication related to cognitive impairment and included that the call light should be in reach. A quarterly MDS assessment showed a BIMS score of 5, indicating severe cognitive impairment, and the resident required substantial to maximal assistance for personal hygiene, bathing, and toileting. During observations on 12/8/2025, Resident #41 was seen lying in bed multiple times with the call light hanging over the headboard and not within reach. At one observation, the resident was holding a chicken salad sandwich and some of the contents had fallen onto the resident’s clothing. During an observation and interview, the resident stated that when she needed assistance from staff, she pushed a button. LPN F confirmed the call light was out of the resident’s reach, and CNA J, CNA G, and the DON stated the resident was able to activate the call light and that it was expected to be in reach at all times.
Failure to Follow and Update Orthotic Care Plans
Penalty
Summary
The facility failed to implement the comprehensive care plan for Resident #12 after the resident returned from the hospital with a new diagnosis of a right distal fibula fracture and a physician order for a tall walking boot at all times. The care plan dated 9/12/2025 stated the resident was to wear the boot on the right leg at all times and could remove it only during showers, but it did not document the right ankle fracture. Resident #12 had a BIMS score of 14, indicating cognitive intactness, and required substantial to maximal assistance with putting on and taking off footwear. During observations on 12/8/2025 and 12/9/2025, the boot was found lying on a chair while the resident was in bed, and the resident stated staff did not put it on and that she was not wearing it. The facility also failed to update the care plan for Resident #39 after repeated refusal of a left wrist/hand splint. The resident had diagnoses including history of stroke with hemiplegia, weakness, and contractures of the left arm, hand, and wrist, and the care plan directed staff to apply the splint early in the morning after gentle stretching and remove it in the afternoon. The resident had a BIMS score of 15, was dependent on staff for dressing, and did not reject care, but observations on 12/8/2025 and 12/9/2025 showed the resident without the splint on the left wrist or hand. The resident stated she did not wear the splints because they hurt and told an OT, and the TAR documented refusals from 12/1/2025 through 12/10/2025, while the nurse's notes contained no documentation of the refusals. The RN/DQM confirmed staff were expected to follow the care plan for orthotic use and that the resident's refusal was not reflected in the care plan.
Incomplete meal intake documentation and missed nutritional supplement administration
Penalty
Summary
The facility failed to ensure accurate documentation of a resident’s meal intake, which prevented determination of whether the resident met the criteria for receiving an ordered nutritional supplement. Resident #2 was admitted with diagnoses including Specified Nutritional Anemia, Dysphagia, History of Subdural Hematoma, and Chronic Migraines. The care plan identified the resident as at risk for unintended weight loss related to inadequate intake and dysphagia and directed nutritional supplements as ordered. A physician’s order dated 11/20/2025 directed staff to give one container of Jevity if the resident ate 50% or less at meals, three times daily. The resident’s MDS indicated a BIMS score of 15 and that the resident could feed himself with setup or clean-up assistance. Review of meal intake documentation from 12/1/2025 through 12/10/2025 showed 28 meals, with 5 meals documented as 25-50% consumed, but the entries did not specify whether the intake was 25% to 49% or 50%. In addition, 8 of the 28 meals had no intake percentage documented at all. The TAR showed the Jevity supplement was signed off as N-Treatment Not Administered for all 28 meals, and there was no documentation of the reason it was not given. Nursing progress notes also contained no explanation for the missed supplement administration. The DON stated staff were expected to document intake at every meal and to administer Jevity according to physician orders, and confirmed the intake documentation was incomplete and the supplement was not administered.
Insufficient Nursing Staff for High-Acuity Hallway
Penalty
Summary
The facility failed to ensure sufficient nursing staff based on resident acuity on the 800-west hallway. The facility policy for answering call lights stated resident requests and needs should be responded to as soon as possible, and the facility assessment stated staffing ratios and assignments were to be based on resident census, resident need, and acuity, with assignments modified to reflect resident needs. Facility documentation showed that 9 of 18 residents on the hallway required 2-person assistance, and 4 of those residents required a Hoyer lift. Resident council minutes documented repeated staffing concerns on the 8th floor west hallway, including requests for a third CNA and concerns about lack of CNA support for Hoyer needs and transfers. The medical records showed multiple high-acuity residents on the hallway, including residents who required total or extensive assistance with bathing, dressing, toileting, bed mobility, transfers, and incontinence care. One resident had diagnoses including Parkinsonism, left femur fracture, and muscle wasting and atrophy; another had diabetes, morbid obesity, and hemiplegia following cerebrovascular disease; another had functional quadriplegia, a C5 spinal cord lesion, and required 2-person staff support with transfers and turning; and another had quadriplegia, morbid obesity, and required total assistance with transfers and bed mobility. During observation, one resident’s call light remained unanswered for 20 minutes and was answered after 29 minutes, while the resident stated staff were slow to respond and had not checked what she needed. Staff interviews consistently described the hallway as having 2 CNAs and 1 nurse on day shift despite multiple residents requiring 2-person assistance and some needing up to 1 1/2 to 2 hours for care. CNAs, an LPN, an RN, the DON, the Administrator, and the Director of Clinical Operations all acknowledged that call lights were not always answered timely, that the hallway had high acuity, and that staffing needed to be adjusted to meet resident needs timely.
Controlled Medication Reconciliation Not Completed
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when controlled medications were not reconciled for 3 of 8 residents reviewed. The facility policy titled, Medication Administration, dated 12/2025, stated that if a medication is a controlled substance, it should be signed in the narcotic book. During observation of the 700 East Medication Cart, the Controlled Drug Record for Resident #86 showed oxyCODONE 10/325 mg with an amount left of 8, while the narcotic card showed 7 tablets remaining. RN N stated the resident had refused an earlier dose and it needed to be wasted with the supervisor, and that there were 7 tablets in the package, not 8. For Resident #13, the Controlled Drug Record showed traMADol 50 mg with an amount left of 23, while the narcotic card showed 22 tablets remaining. RN N stated she had given the resident a dose earlier, had signed it off in the computer, but had not yet signed it off in the narcotic reconciliation sheet. For Resident #67, the Controlled Drug Record showed traMADol 50 mg with an amount remaining of 6, while the narcotic card showed 5 tablets remaining. RN N stated she had given the resident a dose earlier and had not written it in the book yet. The DON confirmed narcotics should be signed out on the narcotic reconciliation sheet as soon as they were administered to a resident.
Failure to Offer Hand Hygiene Assistance Before Meal Service
Penalty
Summary
Infection prevention and control practices related to hand hygiene were not followed during meal service when a CNA failed to offer hand hygiene assistance to Resident #24 before the lunch meal. The facility policy titled Hand Hygiene, revised 6/2025, stated that encouragement, reminders, and/or assistance with hand hygiene is provided to residents before meals. Resident #24 was admitted with diagnoses including hemiplegia and need for assistance with personal care, and the quarterly MDS showed a BIMS score of 3, indicating severe cognitive impairment, with needs for supervision or touching assistance with eating and partial to moderate assistance with personal hygiene. The comprehensive care plan for Resident #24 documented a need for total assistance with hygiene/oral care and assistance with meal tray setup. During observation on 10/8/2025 at 12:24 PM, CNA K carried the meal tray down the 800 hallway, brought it into Resident #24's room, opened the silverware, picked up the resident's drink, placed a straw in it, and opened the food cover. Resident #24 then picked up his fork and began eating, and CNA K did not offer hand hygiene assistance before the meal. CNA K later stated she failed to offer hand hygiene assistance, and the DON stated staff were to complete hand hygiene before assisting with meal tray setup and to offer hand hygiene assistance to all residents before serving meals.
Failure to Maintain a Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for two residents, as observed during a survey. Resident #12, who has moderate cognitive impairment due to Multiple Sclerosis and other conditions, was found in a room where the bottom trim baseboard was coming apart from the wall, with gouges in the paint and drywall. Blue tape was used to cover these gouges, and Resident #12 was unsure how long the tape had been there. Similarly, Resident #7, who has severe cognitive impairment due to Dementia and other health issues, was found in a room with multiple tears in the paint and drywall behind the headboard of their bed. The facility's administrator confirmed that the conditions in both rooms did not reflect a homelike environment, acknowledging the need for repairs.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to develop Enhanced Barrier Precautions (EBP) on the comprehensive care plans for three residents with indwelling urinary devices. Resident #36, who was cognitively intact, had a suprapubic catheter for a neurogenic bladder, but the care plan did not include EBP. Observations revealed no EBP signage or Personal Protective Equipment (PPE) available in or outside the resident's room. Interviews with staff, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), indicated a lack of awareness regarding the need for EBP during catheter care. Resident #12, with moderate cognitive impairment, also had an indwelling catheter for a neurogenic bladder, yet EBP was not included in the care plan. Observations confirmed the absence of EBP signage and PPE. Interviews with the Registered Nurse (RN) House Supervisor and CNAs revealed that the resident was not placed in EBP, and staff only wore gloves during catheter care, indicating a lack of implementation and awareness of EBP requirements. Resident #24, with moderate cognitive impairment and a suprapubic catheter for neurogenic bladder, similarly lacked EBP in the care plan. Observations showed no EBP signage or PPE, and interviews with the Infection Preventionist and an LPN confirmed the absence of EBP implementation for this resident. The Infection Preventionist acknowledged that residents with indwelling devices should be placed on EBP, but this was not done for the three residents in question.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with indwelling devices, as required by their infection prevention and control program. The facility's policy mandates the use of gowns and gloves during high-contact activities for residents with indwelling medical devices, regardless of infection or colonization status. However, observations and interviews revealed that staff were not following these precautions for residents with suprapubic and indwelling catheters. Resident #36, who has a suprapubic catheter due to neurogenic bladder, did not have EBP signage or personal protective equipment (PPE) available in or outside their room. Interviews with the resident and staff, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), indicated that only gloves were used during catheter care, and there was a lack of awareness about the need for EBP. Similarly, Resident #12, with an indwelling catheter, and Resident #24, with a suprapubic catheter, also lacked EBP signage and PPE. Interviews with staff, including a Registered Nurse (RN) House Supervisor, CNAs, and the Infection Preventionist, confirmed that EBP was not implemented for these residents. The staff were unaware of the requirement for additional PPE beyond gloves during catheter care, indicating a systemic failure to adhere to the facility's infection control policy.
Inaccurate MDS Assessment for Resident with Fall Incident
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident, identified as Resident #6, as required by the Centers for Medicare and Medicaid Services (CMS) guidelines. The facility's policy mandates that MDS assessments be completed based on information from various sources, including the resident, family, physician, caregivers, and clinical assessments. These assessments are crucial for developing a comprehensive plan of care. However, a review of the quarterly MDS assessment for Resident #6, dated January 25, 2024, revealed that no falls were documented since the prior assessment, despite evidence to the contrary. Resident #6 was admitted with multiple diagnoses, including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Bipolar Disorder, Weakness, Vascular Dementia, and Adult Failure to Thrive. The comprehensive care plan for this resident, revised on December 27, 2023, indicated a potential for falls, with interventions such as using a wedge for support. On the same day, the resident was found on the floor beside the bed and was transported to the emergency department for further evaluation. During an interview, the Interim MDS Coordinator confirmed that the resident had experienced a fall on December 27, 2023, and acknowledged the inaccuracy in the MDS assessment dated January 25, 2024.
Failure to Remove Discontinued Narcotics from Inventory
Penalty
Summary
The facility failed to ensure that discontinued narcotics were removed from inventory in a timely manner, leading to discrepancies in medication documentation for a resident. According to the facility's policy on discarding and destroying medications, unused controlled substances should be counted each shift and marked with a red X until properly disposed of. However, the facility did not adhere to this policy for a resident who was prescribed Percocet, a narcotic for pain, which was discontinued but not removed from the inventory. The resident, who had severe cognitive impairment, was admitted with diagnoses including Alzheimer's Disease and Mood Disorder. Despite the discontinuation of Percocet on a specific date, the medication was documented as withdrawn from inventory by an RN five days later, with no corresponding administration record. The resident did not report any pain or request for medication, and there was no recollection of the RN's presence in the room, raising concerns about potential medication diversion. The facility's investigation revealed that the RN involved did not respond to multiple attempts to discuss the irregularities. The DON confirmed that the failure to remove the discontinued medication from the cart led to the incident. The facility concluded that had the medication been removed and destroyed as per policy, the discrepancy would not have occurred.
Incomplete Medical Record Documentation for Resident Fall
Penalty
Summary
The facility failed to maintain a complete medical record for a resident, specifically regarding an unwitnessed fall that occurred on January 25, 2024. The facility's policy requires that any changes in a resident's condition, such as falls, be documented in the medical record. However, the fall was not recorded at the time of occurrence. The resident, who had a history of falls and was diagnosed with muscle weakness, dementia, and general anxiety disorder, was found sitting on the floor by a clothes closet after the fall. The incident was not documented by the responsible nurse, and the facility was only made aware of the fall after an Environmental Services employee reported a new skin injury on the resident. Interviews revealed that the fall was not documented by an agency nurse, who was later terminated. The Director of Nursing confirmed that the nurse did not follow the facility's policy by failing to chart the fall in the medical record. The incident was discovered after a Licensed Practical Nurse found a skin tear on the resident's forearm, which was also not documented. The facility initiated an investigation into the injury of unknown origin after being alerted by the Environmental Services employee.
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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.
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Nursing homes near Signal Mountain
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Red Bank | 2.7 mi | ★★★★★ | 0 | 0 |
| Siskin Subacute West | 6.6 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Hixson | 8 mi | ★★★★★ | 4 | 1 |
| Nhc Healthcare, Chattanooga | 8.3 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare Rossville | 11.5 mi | ★★★★★ | 0 | 0 |
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