Below 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 Rocky Top Care Center during CMS and state inspections, most recent first.
Dirty Nourishment Room Microwaves: Two microwaves used by staff to heat resident food were observed with visible food splatter, crusty residue, and crumbs inside. Cleaning logs did not include the Nourishment Rooms, and the CDM stated there was no set policy, only that dietary should check and clean the microwaves daily as needed.
Failure to Notify Resident Representative of Care Plan Conferences: A resident with dementia, DM, and anxiety had a care plan initiated and revised, but the record showed only one documented care conference with the RP by phone and no documentation of other invitations or attendee lists. The RP stated she was not invited to care plan conferences, while the SSD said she was responsible for scheduling and inviting the RP and was not keeping a schedule for required care plan meetings.
Unlabeled and undated food was found in two residents’ personal refrigerators, and one resident also had expired bread available for use. The facility policy required outside food and prepared food stored in resident refrigerators to be labeled, dated, and discarded within the required timeframe, but staff observed containers, sandwiches, and bread that were not properly dated or stored. One resident had moderate cognitive impairment and the other had severe cognitive impairment.
The facility failed to handle residents' laundry safely, exposing them to pathogens, and allowed COVID-19 positive staff to work with non-COVID-19 residents, increasing infection risk. Additionally, inadequate staffing led to missed outpatient appointments and showers for residents.
The facility's QAPI program failed to identify and address deficiencies in infection control practices, leading to improper handling of residents' laundry and premature return of COVID-19 positive staff. This oversight resulted in a COVID-19 outbreak affecting 22 residents and 13 employees, with seven staff returning to work before completing isolation. The facility also had repeated abuse-related deficiencies, which were not effectively addressed by the QAPI committee.
The facility failed to maintain sanitary conditions for residents' personal laundry, which was improperly handled and stored, leading to insufficient cleaning. Additionally, the facility did not adhere to CDC guidelines for excluding COVID-19 positive employees from work during an outbreak, increasing the risk of virus spread. The facility also failed to post Enhanced Barrier Precautions signage on three resident rooms, placing residents at risk of serious harm.
The facility's Governing Body failed to address unsafe handling of residents' laundry and allowed COVID-19 positive staff to work with non-COVID-19 residents, exposing all residents to infection. The QAPI program did not identify or address these deficiencies, leading to a COVID-19 outbreak affecting 22 residents and 13 employees.
The facility failed to maintain adequate staffing, resulting in two residents missing outside physician appointments and five residents not receiving scheduled showers. Interviews and documentation revealed that low staffing levels often prevented CNAs and LPNs from completing scheduled care tasks. The facility's staffing goals were not met, leading to unmet care needs.
A dietary aid in the facility's kitchen was observed without a protective beard covering, violating the facility's sanitary practices policy. The policy requires all hair, including facial hair, to be covered to ensure sanitary conditions. The Dietary Manager confirmed the oversight, which had the potential to affect all 90 residents.
The facility failed to provide scheduled showers for five residents due to staffing issues, despite residents not refusing care. Staff interviews revealed that CNAs and LPNs were unable to complete scheduled showers due to high resident-to-staff ratios. The Director of Nursing Services and the Administrator acknowledged the staffing concerns, confirming that some residents did not receive their scheduled showers.
The facility did not serve meals simultaneously to residents seated at the same table during a lunch meal, violating their right to a dignified existence. Several residents experienced delays in receiving their meals, with one resident waiting 13 minutes after expressing hunger and another receiving their meal 17 minutes after others at the same table. An error was also noted where a meal was left in a resident's room, causing further delay.
A deficiency was identified in a facility's ADL documentation for several residents, revealing incomplete and inaccurate records of scheduled showers. Interviews with CNAs indicated that low staffing levels often prevented them from providing scheduled showers or completing documentation. The DNS confirmed the discrepancies, acknowledging that the incomplete records resulted in an inaccurate medical record.
A facility failed to maintain a clean and homelike environment for a resident with severe cognitive impairment. The resident's bathtub was repeatedly observed with dead insects and dirt-like substances, which was confirmed by the Administrator as unsanitary and not in line with the facility's policy for a safe and comfortable environment.
Two incidents of resident-to-resident abuse occurred in the facility, involving residents with severe cognitive impairments. In one case, a resident punched another in the face, and in the second case, a resident struck another twice. Both incidents were witnessed by staff, who intervened, but the facility failed to prevent the abuse despite existing care plans for aggressive behavior.
The facility failed to provide transportation for two residents to their scheduled medical appointments due to insufficient staff. One resident missed multiple urology appointments, while another missed a gastroenterology appointment. Despite the missed appointments, facility staff indicated that no harm resulted to the residents.
Expired medications and supplies were found in a medication room, including syringes, suppositories, and Heparin Lock Flush Solutions. An LPN confirmed these items were expired and available for resident use, contrary to the facility's policy requiring their removal and disposal. The DNS acknowledged the oversight.
The facility failed to properly contain garbage and refuse in three dumpsters, as required by their 'Waste Control' policy. During an observation, it was found that dumpsters A, B, and C were missing drain plugs, leaving openings that exposed the contents to the air and potential pests. The Dietary Manager confirmed the absence of drain plugs, leading to improper containment.
The facility's assessment failed to include staffing parameters for the secure unit, contingency staffing protocols, and changes in laundry services. It also lacked input from direct-care staff, residents, or families.
The facility failed to report abuse allegations to the state agency within the required 2-hour timeframe for six residents, resulting in significant delays. Residents with cognitive impairments experienced delays in reporting incidents of verbal and physical abuse, with some reports delayed by over 20 hours. Interviews confirmed the facility's failure to adhere to mandatory reporting requirements.
The facility failed to conduct thorough investigations for injuries of unknown origin and abuse allegations involving several residents with cognitive impairments. A resident sustained a rib fracture without a complete investigation, and another incident involved resident-to-resident altercations without proper documentation or interviews. Additionally, the facility did not notify physicians or family representatives after abuse allegations, and the Administrator acknowledged issues with incomplete investigations.
The facility failed to protect residents from verbal and physical abuse. A resident with moderate cognitive impairment reported verbal abuse by a CNA, which was substantiated. Additionally, two residents with severe cognitive impairment were involved in a physical altercation, resulting in injury. Another resident attempted to assault a fellow resident but was stopped by staff. The facility's administrator confirmed these failures.
The facility did not update care plans for four residents after incidents of abuse and allegations of abuse, despite policy requirements. A resident with moderate cognitive impairment reported verbal abuse by a CNA, and another resident reported a CNA being rude and threatening, but their care plans were not revised. Additionally, two residents involved in a resident-to-resident altercation did not have their care plans updated. The DON confirmed the care plans were not revised following these incidents.
The facility did not submit required PBJ data to CMS for four consecutive quarters, covering the 3rd and 4th Quarters of 2022 and the 1st and 2nd Quarters of 2023. The Administrator admitted responsibility for the oversight during an interview.
Dirty Nourishment Room Microwaves
Penalty
Summary
The facility failed to ensure 2 of 3 microwaves available for resident use were maintained in a clean and sanitary condition. Review of the Daily/Weekly Cleaning Logs dated 2/1/2026 through 2/28/2026 showed the Nourishment Rooms, which included the microwaves, were not listed on the daily/weekly cleaning schedule. During observations on 3/2/2026, surveyors found the microwave in one Nourishment Room with brown, tan, and orange substances splattered on the top, sides, and bottom of the interior, along with gray and white crusty substances, food debris, and crumbs on the interior and glass plate; CDM A confirmed it was dirty. A second microwave in another Nourishment Room was also observed with orange, tan, and yellow substances splattered on the interior, plus a brown sticky substance and crumbs on the bottom; Regional CDM L confirmed it was dirty. During interview, Regional CDM L stated there were no cleaning logs for the Nourishment Rooms and that staff just wiped them down as they went. On 3/4/2026, surveyors again observed both microwaves in the same condition, with visible splatter, crusty residue, and food debris remaining inside. Regional CDM L again confirmed the microwaves were dirty. Staff interviews on 3/4/2026 showed that LPNs and CNAs used the Nourishment Room microwave to heat resident food when needed, and Regional CDM L stated there was no set policy, but dietary should be checking the microwaves daily and cleaning them as needed because they were considered an extension of the kitchen.
Failure to Notify Resident Representative of Care Plan Conferences
Penalty
Summary
The facility failed to provide resident and resident representative notice of quarterly care plan conferences for one resident with dementia with psychotic disturbance, diabetes mellitus, and generalized anxiety disorder. The facility policy required care conferences to involve the resident and/or representative, be held at admission and at regular intervals, and be scheduled and documented by the Social Services Director or designee. Review of the record showed the resident’s comprehensive care plan was initiated and later revised, with diagnoses including generalized anxiety disorder and dementia with behavioral disturbances, but the only documented care plan conference was a telephone conference with the responsible party on 10/14/2024. The resident’s quarterly MDS assessments showed severe cognitive impairment, with BIMS scores of 4 and later 2. The record also contained Social Services notes about discussing exit-seeking behavior and a possible room change with the daughter, but there was no documentation that the resident’s representative was invited to or involved in other care plan conferences or revisions. During interview, the responsible party stated she had not attended or been invited to care plan conferences. The Administrator stated the Social Services Director was responsible for scheduling and inviting residents or representatives and confirmed care plan meetings should be documented with all attendees, while the Social Services Director stated she had not been keeping a schedule and was unsure whether any care plan meetings occurred beyond the two noted contacts.
Unlabeled and Undated Food Found in Resident Refrigerators
Penalty
Summary
The facility failed to ensure food storage safety requirements were met for two residents with personal room refrigerators. The facility policy titled, Use & Storage of Food from Outside Sources, required food brought in from outside sources to be monitored for spoilage, contamination, and safety, and required cooked or prepared food stored in a resident’s refrigerator to be dated when accepted and discarded after 24 hours. The Administrator stated resident refrigerators were checked daily for temperatures and spot checked for cleanliness and dated or expired items, and that outside food brought in by family was to be labeled, dated, and discarded within 3 days. Resident #40, who had diagnoses including Neurocognitive Disorder with Lewy Bodies, Bipolar Disorder, Dementia with Agitation, and Diabetes and a BIMS score indicating moderate cognitive impairment, had two black plastic food containers with transparent lids in the personal refrigerator that were unlabeled and undated. The resident stated he did not know what was in the containers or how long they had been there, and an LPN stated the containers had been brought in by the resident’s family on Sunday. Resident #17, who had diagnoses including Schizoaffective Disorder, Diabetes Mellitus, Muscle Weakness, and Vascular Dementia and a BIMS score indicating severe cognitive impairment, had a whole sandwich and two half sandwiches in unsealed plastic bags that were unlabeled and undated in the personal refrigerator, along with a loaf of white bread on top of the refrigerator that was expired. A CNA confirmed the bread was expired and the sandwiches were unsealed, unlabeled, undated, and available for resident use.
Inadequate Infection Control and Staffing in LTC Facility
Penalty
Summary
The facility's administration failed to ensure the safe and sanitary handling, storage, processing, and transportation of residents' personal laundry, potentially exposing 85 of 90 residents to infectious pathogens. The facility had ceased using a commercial laundry service and instead transported soiled laundry to a local laundromat, where it was washed without proper sanitizing agents and at insufficient water temperatures. Observations revealed that residents' laundry was stored in unsanitary conditions, with dried feces and urine, and not separated, leading to potential microbial contamination. Additionally, the administration failed to exclude COVID-19 positive employees from work for the required isolation period as recommended by the CDC. During a COVID-19 outbreak, the facility allowed symptomatic and COVID-19 positive staff to work with non-COVID-19 residents, increasing the risk of spreading the infection. Interviews confirmed that several employees returned to work before completing the recommended quarantine period, contrary to CDC guidelines. The facility also failed to maintain adequate staffing levels, resulting in two residents missing scheduled outpatient appointments due to insufficient staff for transportation. Furthermore, five residents did not receive their scheduled showers due to staffing shortages. Interviews with staff and administration confirmed awareness of these staffing issues, which impacted the facility's ability to meet residents' care needs, including transportation and personal hygiene.
Inadequate Infection Control and QAPI Oversight
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to effectively identify and address quality deficiencies, particularly in infection control practices. The QAPI committee did not recognize the poor infection control measures in place, which included improper handling, storage, processing, and transportation of residents' personal laundry. This oversight had the potential to expose residents to infectious pathogens. Additionally, the facility did not update staff with the latest Centers for Disease Control (CDC) guidelines for isolation and quarantine times for COVID-19 positive employees, resulting in COVID-19 positive staff returning to work prematurely and potentially exposing residents to the virus. The facility experienced a COVID-19 outbreak, during which 22 residents and 13 employees tested positive. Despite this, seven COVID-19 positive employees were allowed to return to work before completing the recommended isolation period. The QAPI meeting minutes from June and July 2024 did not document any identification or reporting of these quality deficiencies, nor did they show any root cause analysis or corrective action plans related to the infection control program and practices. The facility also had repeated deficiencies related to abuse, which were not addressed by the QAPI committee. The facility's administration failed to address the widespread problem of unsafe and unsanitary handling of residents' personal laundry and the premature return of COVID-19 positive employees to work. This failure resulted in an Immediate Jeopardy situation, as the noncompliance with infection control practices had the potential to cause serious harm to all 90 residents. The facility had been previously cited for abuse-related deficiencies, indicating a pattern of noncompliance that the QAPI committee did not effectively address.
Infection Control and COVID-19 Protocol Failures
Penalty
Summary
The facility failed to maintain sanitary conditions for residents' personal laundry, which was stored in a large green bin filled with uncontained soiled clothing items. Observations revealed that the clothing had dried brown substances, smelled of urine, and was difficult to unfold, indicating a lack of proper handling and storage. The facility's process involved placing soiled clothes in a community rolling hamper, bagging them, and storing them in a building behind the facility. The laundry was then taken to a local laundromat, where it was washed without proper separation or the use of necessary chemicals and hot water, leading to insufficient cleaning. Additionally, the facility did not adhere to CDC guidelines for excluding COVID-19 positive employees from work during a COVID-19 outbreak. Employees were not restricted from work for the required isolation period, increasing the risk of exposure and spread of the virus among residents. The facility's outdated COVID-19 policy did not align with the CDC's updated guidance, which required specific criteria for healthcare personnel to return to work after testing positive for COVID-19. The facility also failed to post Enhanced Barrier Precautions signage on the doors of three resident rooms, which is crucial for infection control. This oversight, combined with the improper handling of personal laundry and non-compliance with COVID-19 protocols, placed residents at risk of serious harm. The facility's actions and inactions during the COVID-19 outbreak and in managing personal laundry contributed to the deficiencies identified by the surveyors.
Inadequate Infection Control and Laundry Handling
Penalty
Summary
The facility's Governing Body failed to address significant issues related to the unsafe and unsanitary handling, storing, and processing of residents' contaminated and potentially hazardous personal laundry. This failure had the potential to expose infectious pathogens to 85 of the 90 residents who utilized the facility's laundry service. Additionally, the Governing Body did not provide effective leadership and oversight to ensure that COVID-19 positive employees were excluded from work for the required isolation period as recommended by the Centers for Disease Control (CDC). This oversight allowed COVID-19 positive staff to work with non-COVID-19 residents, thereby exposing all 90 residents to the risk of infection. The facility experienced a COVID-19 outbreak from June to August 2024, during which 22 residents and 13 employees tested positive for the virus. Interviews revealed that seven employees returned to work before completing the CDC-recommended quarantine period. The facility's Quality Assurance and Performance Improvement (QAPI) program failed to identify and address quality deficiencies, perform root cause analyses, or develop corrective action plans related to the infection control program and laundry services. The QAPI meeting minutes from June and July 2024 showed no documentation of efforts to address these issues. The facility's administration and Governing Body did not adequately address the widespread problems of infection control and laundry handling in their QAPI meetings. The Administrator acknowledged areas needing improvement in infection prevention and control practices. The facility's policies and procedures, including those related to the Governing Body's responsibilities, were not effectively implemented to ensure compliance with state and federal regulations, thereby placing residents in Immediate Jeopardy.
Staffing Shortages Lead to Missed Appointments and Unmet ADL Needs
Penalty
Summary
The facility failed to maintain adequate staffing levels, resulting in two residents missing scheduled transportation to outside physician appointments. One resident, who was cognitively intact, missed multiple urology appointments due to transportation issues caused by insufficient staff. Another resident, with moderate cognitive impairment, missed an appointment with a stomach doctor because there was not enough staff available to transport or assist him to the appointment. The Director of Nursing Services and the Administrator confirmed these incidents were due to staffing shortages. Additionally, the facility did not meet the ADL needs of five residents, specifically in providing scheduled showers. Residents who required assistance or supervision for showers did not receive them as scheduled, with some receiving no showers for entire months. Interviews with CNAs and LPNs revealed that low staffing levels often prevented them from completing scheduled showers, despite residents not refusing them. The facility's staffing schedule and actual punch times showed discrepancies, with shifts often operating with fewer staff than planned. The facility's staffing goals were not met, as confirmed by the Director of Nursing Services and the Administrator. The secure unit, east hallway, and west hallway frequently operated with fewer CNAs and nurses than required, leading to unmet care needs. The Administrator acknowledged awareness of staffing concerns and confirmed that some residents did not receive scheduled showers due to these issues. The facility's assessment indicated a need for more staff than were actually scheduled, contributing to the deficiencies in resident care.
Non-compliance with Sanitary Practices in Kitchen
Penalty
Summary
The facility failed to ensure compliance with its sanitary practices policy, specifically regarding the requirement for kitchen staff to wear protective coverings for facial hair. During an observation in the food preparation area, a dietary aid was found without a protective beard covering, which is a violation of the facility's policy dated 1/1/2017. This policy mandates that all hair, including facial hair, must be completely covered to maintain sanitary conditions. The Dietary Manager confirmed the deficiency during an interview, acknowledging that the dietary aid's beard was not fully covered while working in the kitchen, potentially affecting all 90 residents of the facility.
Failure to Provide Scheduled Showers Due to Staffing Issues
Penalty
Summary
The facility failed to provide scheduled showers for five residents, leading to a deficiency in the care and assistance with activities of daily living (ADLs). The facility's policy states that all residents have the right to a dignified existence and self-determination, which includes receiving scheduled showers. However, documentation and interviews revealed that residents did not receive their scheduled showers consistently over several months. For instance, one resident was scheduled for showers twice a week but received only a few showers over a three-month period, despite not refusing them. Interviews with staff, including CNAs and LPNs, indicated that staffing issues contributed to the failure to provide scheduled showers. Staff members reported being unable to complete the scheduled showers due to the high number of residents they were responsible for during their shifts. The Director of Nursing Services and the Administrator acknowledged the staffing concerns and confirmed that some residents had not received their scheduled showers. Observations of the residents involved showed that they were not unkempt and no odors were noted, suggesting that some level of personal care was maintained. However, the lack of documentation and completion of scheduled showers indicates a systemic issue in meeting the residents' ADL needs. The facility's failure to adhere to its own policies and ensure adequate staffing levels resulted in the deficiency noted by the surveyors.
Failure to Serve Meals Simultaneously in Dining Room
Penalty
Summary
The facility failed to honor the residents' right to a dignified existence and self-determination by not serving meals simultaneously to residents seated at the same table during a lunch meal observation. The facility's policy on Dining and Meal Service, which mandates that individuals at the same table be served and assisted at the same time, was not adhered to. This resulted in four residents experiencing delays in receiving their meals compared to others at their tables. For instance, one resident expressed hunger and had to wait 13 minutes after requesting his meal, while another resident received their meal 17 minutes after others at the same table had been served. The deficiency was further highlighted by an incident where a resident's meal was mistakenly left in their room, causing additional delay in service. The Activity Director confirmed this error during an interview. The Regional President acknowledged that residents were supposed to be served one table at a time and confirmed the untimely service during the lunch meal. The residents involved had various medical conditions, including dementia, depression, and diabetes, with some requiring assistance with eating, which underscores the importance of timely meal service.
Deficiency in ADL Documentation Due to Staffing Issues
Penalty
Summary
The facility failed to ensure the medical records were accurate and complete for four residents, leading to a deficiency in the documentation of Activities of Daily Living (ADL) care. The facility's policy requires maintaining complete and accurate records, but reviews revealed significant gaps in the documentation of scheduled showers for the residents. For instance, Resident #33, who was cognitively intact and required supervision with bathing, received significantly fewer showers than scheduled over several months, with many days left undocumented or marked as Resident Not Available (RNA) or Not Applicable (N/A). Interviews with Certified Nursing Assistants (CNAs) highlighted issues contributing to the deficiency. CNA B, who regularly worked on the resident's hall, reported that low staffing levels often prevented her from providing scheduled showers or completing documentation. Similarly, CNA C and CNA O noted that they were unable to complete scheduled showers or document them due to time constraints, despite Resident #33 not typically refusing showers. These staffing challenges and documentation lapses were consistent across the other residents reviewed, including Resident #39, who was severely cognitively impaired and dependent on staff for all ADLs, and Resident #49, who was cognitively intact but required assistance. The Director of Nursing Services (DNS) confirmed the discrepancies in the ADL bathing records during an interview, acknowledging that the residents had not received the scheduled showers and that some baths were not documented. The DNS expressed that the incomplete records resulted in an inaccurate medical record, indicating a failure to chart properly. This deficiency in maintaining accurate and complete medical records for residents' ADL care reflects a significant lapse in the facility's adherence to its own policies and professional standards.
Failure to Maintain a Clean Environment for a Resident
Penalty
Summary
The facility failed to provide a clean and homelike environment for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including difficulty walking, weakness, and lack of coordination, was observed in their room on multiple occasions with a bathtub containing dead insects and a brownish, black dirt-like substance around the drain. These observations were made over several days and confirmed by the facility's Administrator, who acknowledged that the bathtub had not been maintained in a sanitary manner, thus failing to meet the facility's policy on providing a safe, clean, and comfortable environment for residents.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two separate incidents involving resident-to-resident altercations. In the first incident, Resident #45, who has severe cognitive impairment and a history of impulsiveness, punched Resident #22, who also has severe cognitive impairment, in the face. This incident occurred in the dining room and was witnessed by a CNA, who immediately intervened. Despite the intervention, the altercation resulted in physical abuse, although no injuries were observed on Resident #22. In the second incident, Resident #13, who has severe cognitive impairment and a history of psychotic disturbances, struck Resident #54 twice in the face. This altercation was reported by another resident and witnessed by staff, who separated the residents. Resident #54, who has moderate cognitive impairment, did not sustain any visible injuries, but the incident was confirmed as physical abuse. The altercation was reportedly triggered by Resident #13's delusion involving a staff member. Both incidents highlight the facility's failure to prevent resident-to-resident abuse, despite having care plans in place for residents with aggressive tendencies. The facility's policies define such altercations as abuse, yet the incidents occurred, indicating a lapse in monitoring and intervention strategies to protect residents from harm.
Failure to Provide Transportation for Medical Appointments
Penalty
Summary
The facility failed to ensure professional standards of practice were followed when transportation was not provided to outpatient scheduled appointments for two residents. Resident #9, who was cognitively intact and had a history of chronic urinary retention and recurrent urinary tract infections, missed multiple urology appointments due to transportation issues. Despite being ready and waiting for transportation, the resident missed appointments on several occasions, including 6/11/2024, 7/22/2024, and 8/13/2024, and was late for an appointment on 6/25/2024, which had to be rescheduled. The Director of Nursing Services confirmed that the missed appointments were due to insufficient staff to provide transportation. Resident #83, who had moderate cognitive impairment and a history of chronic pain and liver disease, also missed a scheduled appointment with a gastroenterologist. The appointment was intended to establish care with a new specialist due to the resident's history of ascites from cirrhosis of the liver. The appointment was scheduled for 8/13/2024 but was rescheduled due to a lack of available staff to transport or assist the resident. The facility's Resident Appointment Scheduler and Administrator confirmed the rescheduling was due to staffing issues. Interviews with facility staff, including the Medical Director and Nurse Practitioner, indicated that the missed appointments did not result in harm to the residents. However, the failure to provide transportation as needed for scheduled medical appointments represents a deficiency in meeting professional standards of care and ensuring residents' rights to access necessary medical services outside the facility.
Expired Medications and Supplies Found in Medication Room
Penalty
Summary
The facility failed to ensure that expired medications and medical supplies were not available for resident use in one of the two medication rooms observed. During an observation and interview in the East medication room, an LPN identified several expired items, including 18 syringes of various sizes, 86 suppositories, and 2 Heparin Lock Flush Solutions. These items were confirmed to be expired and were still stored in the medication room, making them available for resident use. The facility's policy on medication storage, revised in April 2022, mandates the immediate removal and disposal of expired medications. However, during an interview, the Director of Nursing Services confirmed that the expired items should have been removed and placed into the pharmacy return bin for disposal. The failure to adhere to the facility's policy resulted in the availability of expired medications and supplies in the East medication room.
Improper Containment of Garbage in Dumpsters
Penalty
Summary
The facility failed to ensure that garbage and refuse were properly contained in three dumpsters, labeled A, B, and C. According to the facility's policy titled 'Waste Control,' dated January 1, 2012, dumpsters must be kept closed at all times to maintain sanitary conditions. However, during an observation of the outside dumpster area, it was found that all three dumpsters were missing drain plugs, leaving a golf-ball sized opening at the bottom corner of each dumpster. This deficiency left the contents of dumpsters A, B, and C exposed to the air, elements, and potential pests. The Dietary Manager confirmed during an interview that the drain plugs were not intact, resulting in improper containment of the dumpster contents.
Incomplete Facility Assessment
Penalty
Summary
The facility failed to complete a comprehensive facility-wide assessment that accurately reflected the needs and services provided. The assessment, dated 7/28/2024, did not include staffing parameters for the secure unit or contingency staffing protocols for emergency and crisis situations. Additionally, the assessment did not reflect changes in the facility's laundry service or the building modification plans to add an in-house laundry room. Furthermore, there was no documentation indicating that input from direct-care staff, residents, or resident families was considered in the assessment process. During an interview, the Administrator confirmed these omissions in the facility assessment.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the state agency within the required 2-hour timeframe for six residents. The facility's policy mandates that any alleged violations involving abuse or resulting in serious bodily injury must be reported immediately, but no later than 2 hours after the allegation is made. However, the facility did not adhere to this policy, resulting in significant delays in reporting incidents of abuse. Resident #1, who had moderate cognitive impairment, reported feeling afraid of a Certified Nurse Assistant (CNA) and did not want care from them. The incident was reported to the state agency 8 hours and 25 minutes after it was identified. Similarly, Resident #3, also with moderate cognitive impairment, experienced a delay of 9 hours in reporting an allegation of verbal abuse. Resident #4 and Resident #22 were involved in a physical altercation, which was reported 20 hours and 32 minutes after the incident occurred. Additionally, an altercation between Resident #11 and Resident #12, both with cognitive impairments, was reported 9 hours and 45 minutes after it was identified. Interviews with the Director of Nursing Services (DNS) and the Administrator confirmed the facility's failure to report these incidents within the mandatory timeframe. The facility's inability to report these allegations promptly constitutes a deficiency in adhering to regulatory requirements for reporting abuse.
Incomplete Investigations of Injuries and Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations for injuries of unknown origin and allegations of abuse involving several residents. For Resident #13, who had moderate cognitive impairment and was diagnosed with dementia, depression, and seizures, the facility did not complete a comprehensive investigation after the resident sustained a rib fracture. There was no documentation of staff or resident interviews following the identification of the injury, and the Director of Nursing Services (DNS) confirmed that the investigation was incomplete. In another incident, the facility did not perform adequate investigations for resident-to-resident altercations involving Residents #11 and #12, who had moderate to severe cognitive impairments. A Certified Nursing Assistant (CNA) heard yelling in their room and observed red marks on Resident #11, but the facility failed to document skin assessments or conduct interviews with the involved residents and staff. The DNS acknowledged that the investigation was not thorough. Additionally, the facility did not notify the physician or family representatives after allegations of abuse involving Residents #1 and #3, both of whom had moderate cognitive impairments. Resident #1 expressed fear of a CNA, and Resident #3 reported being treated rudely by the same CNA. The facility also failed to conduct complete investigations for an altercation between Residents #4 and #22, neglecting to perform skin assessments and interviews. The Administrator admitted to issues with incomplete investigations.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from verbal abuse and prevent resident-to-resident abuse among four residents. Resident #1, who had moderate cognitive impairment, reported verbal abuse by CNA D, which was substantiated by the facility's investigation. Similarly, Resident #3, also with moderate cognitive impairment, reported that CNA D was rude and talked down to him, which was confirmed by the facility's administrator. In another incident, Resident #27, with severe cognitive impairment, was involved in a physical altercation with Resident #28, who also had severe cognitive impairment. The altercation occurred in the dining room, where Resident #27 hit Resident #28 in the face, resulting in a scratch on Resident #28's face. The facility's investigation confirmed the occurrence of resident-to-resident physical abuse. Additionally, Resident #22, with severe cognitive impairment, attempted to physically assault Resident #4, who had moderate cognitive impairment. Resident #22 was found holding Resident #4's forearms and rearing back with a clenched fist, but intervention by staff prevented further harm. Despite these interventions, the facility failed to protect these residents from physical abuse, as confirmed by the administrator.
Failure to Revise Care Plans After Abuse Allegations
Penalty
Summary
The facility failed to revise comprehensive care plans for four residents following incidents of abuse and allegations of abuse. The facility's policy requires care plans to be revised as residents' conditions change, including after resident-to-resident altercations. However, the care plans for Residents #3, #1, #4, and #22 were not updated after incidents involving verbal abuse and resident-to-resident altercations. Resident #3, who has moderate cognitive impairment, reported verbal abuse by a CNA, but their care plan was not revised. Similarly, Resident #1, who also had moderate cognitive impairment, reported a CNA being rude and threatening, yet their care plan remained unchanged. Additionally, Resident #4, with moderate cognitive impairment, and Resident #22, with severe cognitive impairment, were involved in a resident-to-resident altercation. The facility's investigation documented that Resident #4 held Resident #22's forearms, but neither resident's care plan was updated to reflect this incident. The Director of Nursing Services confirmed that the care plans for these residents were not revised following the allegations of abuse, indicating a failure to adhere to the facility's policy on care plan revisions.
Failure to Submit PBJ Data for Four Quarters
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for four consecutive quarters, specifically the 3rd and 4th Quarters of 2022 and the 1st and 2nd Quarters of 2023. This deficiency was identified through a review of the Quarterly Payroll Based Journal (PBJ) reports, which revealed the absence of submitted data for these periods. During an interview, the Administrator acknowledged that it was his responsibility to submit the PBJ data and confirmed that he did not fulfill this obligation for the specified quarters.
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 63 citations issued within 25 miles in the last 12 months — 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 Rocky Top
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Andersonville Tn Opco Llc | 5.7 mi | ★★★★★ | 8 | 0 |
| The Waters Of Clinton, Llc | 6.7 mi | ★★★★★ | 7 | 0 |
| Cumberland Village Care | 9.5 mi | ★★★★★ | 0 | 0 |
| Tennova Lafollette Health And Rehab Center | 9.7 mi | ★★★★★ | 0 | 0 |
| Diversicare Of Oak Ridge | 14.1 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.