Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Life Care Center Of Crossville during CMS and state inspections, most recent first.
Two residents with PASARR Level II determinations for serious mental illness were not coded accurately on their annual MDS assessments. One resident had diagnoses including major depression, psychotic disorder with delusions, hallucinations, anxiety, and later dementia, while the other had schizophrenia, bipolar disorder, depression, and later anxiety, insomnia, and sleep terrors. Both residents also had quarterly BIMS scores showing severe cognitive impairment, and the RN MDS Coordinator confirmed the MDS coding was inaccurate.
Failure to Obtain Order and Care Plan for CGM Device: A resident with DM used a continuous blood glucose monitoring device secured to the back of her arm and reported readings to nursing staff, but the DON was unaware of the device. The resident stated she ordered the device herself and family brought it from home, while the night nurse applied a new sensor every 10 days. The facility had no physician's order for the CGM and did not include it on the resident's care plan.
Failure to provide ordered adaptive eating devices: A resident with Alzheimer's disease, dysphagia, osteoarthritis, and adult failure to thrive had a physician order for a dycem under tray and plate guard, but observations showed the resident eating without those devices during meals. The DON confirmed the devices were not listed on the meal tray card and the specific adaptive equipment was not documented on the care plan.
The facility failed to update hospice plans of care for four residents receiving hospice services, as required by their hospice contract and policy. The hospice plans of care were not updated in the medical records or communication binders after the certification periods ended, as confirmed by the Social Services Director and Administrator.
A facility failed to resubmit a PASRR after a resident received new mental health diagnoses, including Unspecified Mood Disorder and Schizoaffective Disorder. Despite policy requirements, the facility did not notify the state mental health authority or submit the necessary documentation for a new evaluation. The Admissions Director did not complete the required Level I screening form within the required timeframe, leading to the cancellation of the PASRR submission by Maximus.
The facility failed to properly contain garbage in two of its three dumpsters, as observed during a survey. Dumpsters A and B were missing drain plugs, leaving openings that exposed the contents to the elements and potential pests. The Certified Dietary Manager confirmed the issue, indicating non-compliance with the facility's waste disposal policy.
The facility did not document assessments for potential contraindications to influenza vaccines in the medical records of four residents with various medical conditions. Although assessments were conducted by the DON and IP, they were not recorded, violating the facility's policy.
The facility failed to offer hand hygiene assistance to three residents before meals, as required by its Infection Prevention and Control Program. Despite policies mandating hand hygiene assistance, staff members did not provide this to residents who were either cognitively impaired or dependent on staff for personal hygiene. Interviews confirmed the omission, and the Director of Nursing acknowledged the expectation for staff to offer hand hygiene assistance prior to meals.
A resident with severe cognitive impairment and an indwelling catheter had their urinary drainage bag left uncovered and visible to the public, violating the facility's dignity policy. An LPN confirmed the absence of a privacy cover, and the DON acknowledged the expectation for all bags to be covered.
A resident with diabetes received expired insulin due to a failure in medication management. The insulin lispro was stored and administered past its expiration date, despite facility policies requiring expiration checks. The resident, who was cognitively intact and had a history of diabetes, received the expired medication without any reported negative outcomes. Interviews with facility staff confirmed the oversight and the potential for reduced medication effectiveness.
The facility failed to maintain kitchen equipment in a sanitary condition and did not discard a dented can, potentially affecting all 78 residents. A dented can of kidney beans was found in the dry storage area, which should have been discarded according to the facility's policy. Additionally, the deep fryer had dried food debris and grease-like residue, indicating it required a deep clean.
A resident with multiple medical conditions, including hemiplegia and functional quadriplegia, fell from bed while receiving incontinence care from two CNAs. The resident, who required two-person assistance for transfers, was not adequately supported and rolled out of bed, resulting in injuries. The facility's investigation found that one CNA did not use proper body mechanics, leading to the fall.
A resident with mild cognitive impairment was struck in the face by another resident with severe cognitive impairment in an LTC facility. The incident occurred when the first resident reached for the call light, leading to a temporary reddened area on his cheek. Despite the facility's policy to prevent abuse, the altercation was not prevented, highlighting a failure in monitoring and protecting residents.
A resident's funds were misappropriated by a facility Hospitality Aide, who used the resident's debit card without permission to make unauthorized purchases. The resident, who was cognitively intact and had multiple medical conditions, reported the incident to the Assistant Business Office Manager. An investigation was conducted, leading to the suspension and eventual termination of the Hospitality Aide for violating the facility's code of conduct. The resident's bank reimbursed the stolen amount.
Inaccurate MDS Coding for Level II PASARR Serious Mental Illness
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents who had Level II PASARR determinations for serious mental illness. Resident #39 was admitted with diagnoses including Major Depressive Disorder, Psychotic Disorder with Delusions, Hallucinations, and Anxiety Disorder, and later had Dementia added to the record. A PASARR completed in 2022 determined the resident had a serious mental illness, and a later PASARR update in 2024 noted Dementia but kept the prior Level II determination in effect with no status change. The annual MDS for Resident #39 indicated a serious mental illness and that Level II PASARR had been submitted to the state designated authority, but the assessment was coded inaccurately regarding Level II PASARR. A quarterly MDS also showed a BIMS score of 5, indicating severe cognitive impairment. Resident #47 was admitted with diagnoses including Schizophrenia, Bipolar Disorder, and Depression, with additional diagnoses of Anxiety, Insomnia, and Sleep Terrors/Night Terrors added later. A PASARR completed in 2023 determined the resident met criteria for a serious mental illness, and a later PASARR update in 2024 kept the prior Level II determination in effect with no status change. The annual MDS for Resident #47 also indicated a serious mental illness and that Level II PASARR had been submitted to the state designated authority, but it was coded inaccurately regarding Level II PASARR. A quarterly MDS showed a BIMS score of 8, indicating severe cognitive impairment. During interview, the RN MDS Coordinator confirmed both annual MDS assessments were not coded accurately for being considered by the state Level II PASARR process to have a serious mental illness.
Failure to Obtain Order and Care Plan for Continuous Glucose Monitoring Device
Penalty
Summary
The facility failed to obtain a physician's order before implementing a continuous blood glucose monitoring device for Resident #17 and failed to include the device on the resident's comprehensive care plan. Resident #17 was admitted with diagnoses including diabetes mellitus, history of falling, and depression, and the admission MDS indicated a BIMS score of 14, showing the resident was cognitively intact. The comprehensive care plan addressed diabetes with blood sugar checks as ordered, medication as ordered, and monitoring for signs and symptoms of hyperglycemia and hypoglycemia, but it did not address the continuous glucose monitoring device. During interview and observation, Resident #17 stated she used a device secured to the back of her left arm to monitor blood glucose and reported evening glucose levels from a handheld receiver to the nurse. She stated she ordered the device herself, that family brought it from home, and that the night nurse applied a new device every 10 days because she could not reach the area. The DON stated she was unaware the resident was using the continuous glucose monitoring device, and later confirmed the resident had no physician's order for it and that the care plan did not contain the device until it was identified during survey review.
Failure to Provide Ordered Adaptive Eating Devices
Penalty
Summary
The facility failed to ensure a resident received adaptive eating devices as ordered by the physician. Resident #10 had diagnoses including Alzheimer's Disease, Dysphagia, Osteoarthritis, and Adult Failure to Thrive, and an OT progress note documented that dycem and a plate guard were in place and that nursing was aware. The resident's comprehensive care plan included an intervention for adaptive equipment per order as tolerated, but the specific devices were not documented on the care plan. A physician's order dated 6/27/2025 specified adaptive devices of a dycem under tray and plate guard. Quarterly MDS assessments showed the resident had short-term and long-term memory deficits, severe impairment in cognitive skills for daily decision making, and required set-up/clean-up assistance for eating. During observations of lunch and breakfast meals, the resident was being fed by staff or had the lunch tray in front of her, but did not have a dycem mat under the tray or a plate guard. The DON confirmed during observation and interview that the resident had the physician's order for the dycem mat and plate guard, and also confirmed the adaptive devices were not listed on the kitchen's meal tray card and the specific devices were not documented on the comprehensive care plan.
Failure to Update Hospice Plans of Care
Penalty
Summary
The facility failed to ensure a coordinated plan of care with the hospice provider was available in the medical records for four residents who were receiving hospice services. The facility's hospice contract and policy required that the hospice plan of care be included in the resident's written plan of care and updated regularly. However, upon review, it was found that the hospice plans of care for Residents #6, #19, #21, and #44 were not updated in the medical records or the hospice communication binders located at the nurses' stations. Resident #6, diagnosed with Parkinson's Disease, Diabetes Mellitus, and Heart Failure, had a hospice plan of care that was not updated after the certification period ended on 9/16/2024. Resident #19, with Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and Depression, also lacked an updated hospice plan of care after 12/14/2023. Similarly, Resident #21, with Respiratory Failure, Heart Failure, and Dementia, and Resident #44, with Parkinson's Disease, Depression, and Dementia, did not have updated hospice plans of care after their respective certification periods ended. Interviews with the Social Services Director and the Administrator confirmed the lack of updated hospice plans of care for these residents.
Failure to Resubmit PASRR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to resubmit a Pre-Admission Screening and Resident Review (PASRR) in a timely manner after a new mental health diagnosis was made for a resident. The facility's policy requires coordination with the PASRR program and mandates a referral for a Level II resident review upon a significant change in a resident's mental health status. Despite this, the facility did not promptly notify the state mental health authority or submit the necessary documentation for a new PASRR evaluation after the resident received new diagnoses of Unspecified Mood Disorder, Unspecified Psychosis, and Schizoaffective Disorder. The resident in question had a history of mental health issues, including Major Depressive Disorder, Generalized Anxiety, and Dementia. Over time, the resident received additional diagnoses, which should have triggered a new PASRR submission. However, the facility's Admissions Director did not complete the required Level I screening form or submit the requested information within the required timeframe, leading to the cancellation of the PASRR submission by Maximus, the organization responsible for processing these reviews. Interviews with the facility's Admissions Director and a Maximus Help Desk Representative revealed a misunderstanding regarding the necessity of resubmitting a PASRR for residents with new psychiatric diagnoses, even if they had previously been excluded due to a primary diagnosis of dementia. The facility's failure to comply with the PASRR requirements resulted in a deficiency, as the necessary evaluations and notifications were not conducted in accordance with state regulations.
Improper Containment of Garbage in Dumpsters
Penalty
Summary
The facility failed to ensure that garbage and refuse were properly contained in two of the three dumpsters, specifically dumpsters A and B. According to the facility's policy on the disposal of garbage and refuse, all waste should be properly contained and covered, and areas where garbage is located should be kept clean. However, during an observation of the outside dumpster area, it was noted that dumpsters A and B were missing drain plugs, leaving a golf-ball sized opening at the bottom corner of each dumpster. This deficiency resulted in the dumpsters' contents being exposed to the elements and potential pests. The Certified Dietary Manager (CDM) confirmed during an interview that the drain plugs for dumpsters A and B were not intact, leading to improper containment of the dumpsters' contents. This observation and confirmation highlight the facility's failure to adhere to its own policy regarding waste disposal, thereby compromising the proper containment of garbage and refuse.
Failure to Document Contraindication Assessments for Influenza Vaccines
Penalty
Summary
The facility failed to document assessments for potential contraindications to influenza vaccines in the medical records of four residents. These residents, who had various medical conditions such as Alzheimer's Disease, Diabetes, Dementia, Chronic Obstructive Pulmonary Disease, Functional Quadriplegia, Congestive Heart Failure, Chronic Kidney Disease, and Dysphagia, consented to and received the influenza vaccine. However, their medical records lacked documentation of assessments for contraindications, which is required by the facility's policy. Interviews with the Director of Nursing (DON) and the Infection Preventionist (IP) revealed that while residents were assessed for contraindications at the time of vaccine administration, these assessments were not documented in the medical records. The DON and IP confirmed that assessments included checking for allergies, past reactions to vaccines, and other contraindications such as Guillain-Barre syndrome and acute illnesses. Despite these assessments being conducted, the lack of documentation in the medical records constituted a deficiency according to the facility's policy.
Failure to Provide Hand Hygiene Assistance Before Meals
Penalty
Summary
The facility failed to offer hand hygiene assistance to three residents prior to meals, as observed during meal tray distribution on two of four hallways. The facility's Infection Prevention and Control Program (IPCP) policy, revised on June 13, 2024, mandates that residents should be advised of hand hygiene standards before eating. Additionally, the facility's policy on feeding residents requires staff to assist residents with hand hygiene prior to meals. However, during observations, staff members did not offer hand hygiene assistance to Residents #8, #23, and #16 before delivering their lunch trays. Resident #8, who is cognitively intact but requires setup or clean-up assistance for eating and is dependent on staff for personal hygiene, did not receive hand hygiene assistance from LPN B. Similarly, Resident #23, who is severely cognitively impaired and dependent on staff for eating and personal hygiene, was not offered hand hygiene assistance by LPN C. Resident #16, who is cognitively intact but requires setup or clean-up assistance for eating and is dependent on staff for personal hygiene, also did not receive hand hygiene assistance from CNA D. Interviews with the staff confirmed the omission of hand hygiene assistance, and the Director of Nursing acknowledged that staff were expected to offer such assistance to all residents prior to meals.
Failure to Maintain Resident Dignity by Not Covering Urinary Drainage Bag
Penalty
Summary
The facility failed to uphold the resident's right to dignity by not covering an indwelling catheter drainage bag, leaving it visible to the public. The facility's policy on dignity, dated May 6, 2019, explicitly states that all residents should be treated with dignity and respect, which includes covering urinary catheter bags to prevent demeaning practices. However, during an observation on December 2, 2024, it was noted that a resident's urinary drainage bag was left uncovered and visible from the hallway, violating this policy. The resident involved was admitted with a diagnosis related to a disorder of the kidney and ureter and had an indwelling catheter due to obstruction. The resident's medical records indicated severe cognitive impairment, as evidenced by a score of 0 on the Brief Interview for Mental Status (BIMS) assessment. During an interview, an LPN confirmed the absence of a privacy dignity cover on the resident's urinary drainage bag, and the Director of Nursing acknowledged that all such bags were expected to be covered, confirming the deficiency in maintaining the resident's dignity.
Expired Insulin Administered to Resident
Penalty
Summary
The facility failed to ensure that an expired medication was not available for resident use, specifically affecting one resident who was receiving insulin. During an observation, it was found that insulin lispro, an injectable medication used to lower blood sugar levels, was stored in a medication cart past its expiration date. The insulin was labeled as opened and expired, yet it was still administered to the resident. The Licensed Practical Nurse (LPN) confirmed that the expired insulin was the only cartridge available and had been used for the resident's medication administration. The resident involved had a medical history including diabetes, morbid obesity, and heart failure, and was cognitively intact according to a recent assessment. The resident's care plan included monitoring blood sugar levels and administering medications as ordered. Despite the expired insulin being administered for several days, blood sugar checks did not reveal any negative outcomes. Interviews with the Director of Nursing and the Pharmacist confirmed that the insulin should have been discarded after 28 days, and using it past the expiration date could reduce its effectiveness, although no harm was reported in this case.
Sanitation and Equipment Maintenance Deficiency
Penalty
Summary
The facility failed to maintain kitchen equipment in a sanitary condition and did not discard a dented can, potentially affecting all 78 residents. The facility's policy on sanitation and maintenance, dated April 26, 2023, requires cleaning fixed equipment with detergent and hot water, rinsing, air-drying, and spraying with a sanitizing solution. During an observation and interview on December 2, 2024, with the Certified Dietary Manager (CDM), a 6.88-pound can of dark red kidney beans was found dented on one side in the dry storage area, which was available for resident use. The CDM acknowledged that the kitchen staff checks for dented cans weekly and confirmed that the dented can should have been discarded but was missed during the check. Additionally, during an observation of the cooking area, the deep fryer was found to have dried brownish-yellow food debris with a grease-like residue on the right side. The CDM stated that the deep fryer was last used on November 30, 2024, and was cleaned after use. However, the CDM confirmed that the deep fryer required a deep clean to remove all the grease-like, brownish-yellow food debris present.
Resident Fall Due to Inadequate Support During Care
Penalty
Summary
The facility failed to prevent a fall for a resident, resulting in actual harm. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, diabetes, and functional quadriplegia, was dependent on staff for various activities of daily living, including toileting and transfers. During an incident, the resident was being provided incontinence care by two CNAs when she was rolled onto her side and subsequently fell from the bed to the floor, sustaining injuries. The resident was cognitively intact and required two staff members for assistance with transfers, as documented in her comprehensive care plan. On the day of the incident, while being repositioned in bed by two CNAs, the resident was not adequately supported and rolled out of bed, landing face down on the floor. This resulted in complaints of pain in the neck, head, right arm, shoulder, and index finger, along with visible bruising on the forehead. The facility's investigation revealed that one of the CNAs involved in the incident did not provide proper body mechanics to ensure the resident's safety during the care process. The resident reported that the CNA let her fall, and the facility confirmed that the CNA's actions did not meet the safety needs of the resident during activities of daily living care.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident struck him in the face. Resident #9, who had mild cognitive impairment and required assistance for daily activities, was involved in an altercation with Resident #2, who had severe cognitive impairment and a history of aggressive behavior. The incident occurred when Resident #9 reached for the call light, and Resident #2 struck him in the face, resulting in a temporary reddened area on Resident #9's cheek. The facility's investigation revealed that the incident was reported by Resident #9 to a CNA, and an LPN assessed the situation, confirming the physical contact. Interviews conducted by the LPN indicated that both residents were seated in their wheelchairs when the altercation occurred. Despite the facility's policy to prevent and prohibit all types of abuse, the incident was not prevented, and the residents were not adequately monitored to prevent such occurrences.
Misappropriation of Resident's Funds by Facility Staff
Penalty
Summary
The facility failed to protect a resident's rights to be free from misappropriation and/or exploitation when money totaling $119.49 was taken from a resident. The facility's policy on abuse, neglect, and exploitation, revised on 7/18/2023, defines misappropriation as the deliberate misplacement or use of a resident's property or money without consent. The resident involved was admitted with multiple diagnoses, including Metabolic Encephalopathy, Type 2 Diabetes Mellitus, Morbid Obesity, Acute and Chronic Respiratory Failure, Anxiety, and Quadriplegia. The resident was cognitively intact, as indicated by a score of 15 on the Brief Interview for Mental Status (BIMS) assessment. The incident came to light when the resident informed the Assistant Business Office Manager (ABOM) that her debit card was used without her permission to purchase food at a local restaurant. The ABOM advised the resident to dispute the charges with her bank, which required a police report. The facility initiated an investigation, during which a Hospitality Aide was identified as a suspect and subsequently suspended. The facility substantiated the abuse and terminated the Hospitality Aide for violating the code of conduct. The resident's bank reimbursed her for the disputed amount of $119.49.
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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 Crossville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wyndridge Health And Rehab Ctr | 1.6 mi | ★★★★★ | 10 | 0 |
| Wharton Nursing Home | 9.6 mi | ★★★★★ | 0 | 0 |
| The Preserve At Fairfield Glade | 11.7 mi | ★★★★★ | 0 | 0 |
| Standing Stone Care And Rehab | 19.7 mi | ★★★★★ | 0 | 0 |
| Spring City Care And Rehabilitation Center | 20.3 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.