Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tennessee State Veterans Home- Cleveland during CMS and state inspections, most recent first.
Failure to Protect Resident from Sexual Abuse: A resident with severe cognitive impairment was sexually assaulted by another resident who had a documented history of wandering, entering other residents’ rooms, and sexually inappropriate comments and touching. Staff and the resident reported that he entered her room while she was in bed, removed his clothing, pulled back her covers, and touched her breast. The resident was visibly distraught afterward and later had increased anxiety and insomnia, while the male resident had previously required psych evals and inpatient psych care for similar behaviors.
A resident with intact cognition and diagnoses including DM2, depression, anxiety, suicidal ideation, delusional disorder, and PTSD had her room and belongings searched without consent while she was away from the facility. After a NP saw a prescription bottle in an open nightstand drawer, leadership directed staff to search drawers, the closet, bathroom, refrigerator, and other areas, resulting in removal of marijuana, multiple meds, and other items. The DON confirmed the resident was not present and had not consented, and the DCS stated staff should have only removed items visible in plain sight.
A resident with AFib, weakness, difficulty walking, and a healing humerus fracture was discharged from Medicare Part A while benefit days remained, but the facility only issued a NOMNC and did not provide the required SNF ABN. Records and staff interviews confirmed the resident stayed in the facility as private pay after Part A ended, and leadership acknowledged the ABN was not given and that no staff member was assigned responsibility for SNF ABN notices.
Inaccurate MDS assessments were found for 5 residents. One resident’s death in facility MDS listed the wrong discharge date after the resident expired, and four residents with documented PASRR Level II outcomes for serious mental illness were not coded correctly on significant change MDS assessments. Staff, including the MDS Coordinator, RN MDS, Social Service Director, and Clinical Director of Operations, confirmed the assessments were inaccurate.
Failure to Maintain TBP and EBP: A resident on contact precautions for ESBL in urine was observed with CNAs wearing gown and gloves but discarding PPE in the hallway after leaving the room, contrary to the facility’s isolation instructions. Another resident with a Foley catheter and EBP order was transferred to a wheelchair and had the catheter bag handled by a restorative aide without gown or gloves, despite the EBP sign posted outside the room. The DON and DCS confirmed the expected PPE use for both situations.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from sexual abuse by another resident. The abused resident was admitted with diagnoses including dementia, anxiety disorder, and depression, and her care plan and MDS reflected severe cognitive impairment. The facility policy stated residents have the right to be free from sexual abuse and identified confused and behaviorally disturbed residents as being at increased risk, including residents who enter other residents’ rooms. The incident occurred when a male resident with a documented history of sexually inappropriate behaviors and wandering entered the female resident’s room while she was in bed. According to the resident’s report and staff statements, he removed his lower clothing, pulled back her covers, and touched her left breast. The resident yelled for help, struck him in the lower region, and was visibly distraught afterward. Staff observed the male resident leaving the room without pants on, and his pants were found on the floor near the resident’s bed. The facility’s investigation documented that the male resident had a long history of sexually inappropriate comments, touching, wandering into other residents’ rooms, and being found unclothed in resident rooms, including prior psychiatric hospitalization for these behaviors. After the incident, the female resident was noted to be anxious, tearful, shaken, frightened, and unable to sleep, with multiple notes documenting increased anxiety and insomnia in the days and weeks that followed. A psychiatric evaluation later recorded that she became tearful when discussing the event and stated it was horrible and that she was a little scared and nervous. Her daughter reported the incident upset her and made her worried and cautious. The male resident was placed on one-to-one observation and later transferred for psychiatric hospitalization, but the deficiency was based on the facility’s failure to prevent the resident-to-resident sexual assault from occurring despite the male resident’s known pattern of sexually inappropriate and intrusive behavior.
Unauthorized Search of Resident Room and Belongings
Penalty
Summary
The facility failed to protect a resident’s right to privacy and personal possessions when staff searched the resident’s room and belongings without the resident’s permission and while the resident was not present. The resident was admitted with diagnoses including Type 2 diabetes mellitus, major depressive disorder, anxiety, suicidal ideation, delusional disorder, and post-traumatic stress disorder. An admission MDS assessment documented a BIMS score of 13, indicating the resident was cognitively intact. The record showed that staff found a prescription medication bottle in an open bottom drawer of the resident’s nightstand while a NP was in the room looking for an otoscope. After that observation, leadership directed staff to remove the bottle and search the room further. Staff then searched drawers, the closet, the bathroom, the refrigerator, and a hanging rack on the bathroom door while the resident was out of the facility and had not consented to the search. The DON confirmed the resident was not present and had not given consent, and the Director of Clinical Services confirmed staff should have only removed items visible from the room and should have obtained consent before searching further. The search resulted in the removal of numerous items from the resident’s room, including marijuana cigarettes, mushroom gummies, multiple prescription and OTC medications, topical pain products, inhalers, unlabeled liquid ampules, scissors, lighters, a switchblade utility knife, and other items. The resident stated staff “jimmied” open the locked nightstand and found medication in the drawer, and reported that the drawers were locked and she had the key. The Ombudsman also stated staff searched the resident’s room and belongings without permission and not in the resident’s presence. Facility leadership acknowledged the search occurred after items were observed and that police were not present during the search.
Failure to Provide SNF ABN When Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for Resident #116, who was admitted with diagnoses including atrial fibrillation, muscle weakness, difficulty walking, and a healing fracture of the shaft of the humerus. The record showed the resident had a Medicare Part A skilled services episode that began on 9/12/2025, with the last covered day of Part A service on 11/7/2025, and that the facility initiated discharge from Medicare Part A services while benefit days remained. The resident received a Notice of Medicare Non-Coverage (NOMNC), which stated Medicare coverage would end on 11/7/2025, but the SNF ABN was not provided. Facility documentation and interviews confirmed the resident remained in the facility after the Medicare Part A stay ended and became private pay effective 11/8/2025. A social services progress note documented a discharge planning meeting on 11/10/2025 with the resident and family, during which the private pay rate and NOMNC requirements were discussed. During interviews, the Administrator, Director of Clinical Services, and Social Services Director confirmed the SNF ABN had not been issued, that the facility was only providing NOMNCs, and that no staff member was identified as responsible for providing SNF ABN notices.
Inaccurate MDS Assessments and PASRR Coding
Penalty
Summary
The facility failed to ensure MDS assessments were accurate for 5 of 22 residents reviewed. Facility policy stated that MDS assessments would be completed in accordance with OBRA and Medicare guidelines, and the CMS RAI Manual stated that discharge dates must reflect the date the resident leaves the facility and that residents covered by Level II PASRR may require certain care and services, with PASRR Level II coded as yes when the screening determined the resident had a serious mental illness. For Resident #107, the medical record showed the resident was admitted with multiple diagnoses including a lumbar compression fracture, depression, hypertension, cardiac arrhythmia, hyperlipidemia, sleep apnea, and atherosclerotic heart disease. Nurses notes documented the resident’s time of death and later release to the funeral home, but the death in facility MDS listed an incorrect discharge date. The MDS Coordinator confirmed the resident expired on the date documented in the nurses notes and stated the discharge date on the MDS should have been the actual date of death. For Residents #38, #96, #43, and #54, each record included a prior PASRR Level II outcome related to serious mental illness, but their significant change MDS assessments did not code the PASRR Level II condition. Resident #38 had diagnoses including schizoaffective disorder, depression, and anxiety and a PASRR Level II outcome for serious mental illness; Resident #96 had PTSD, depression, and anxiety with a PASRR Level II outcome; Resident #43 had vascular dementia, adjustment disorder, and bipolar disorder with a PASRR Level II outcome; and Resident #54 had PTSD, recurrent depressive disorder, and impulse disorder with a PASRR Level II outcome. During record review and interviews, the RN MDS, MDS Coordinator, Social Service Director, and Clinical Director of Operations confirmed these MDS assessments were inaccurate and did not reflect the residents’ PASRR Level II outcome status.
Failure to Maintain TBP and EBP
Penalty
Summary
The facility failed to maintain Transmission Based Precautions for a resident with ESBL in the urine and an indwelling catheter. The resident had diagnoses including cerebral infarction, UTI, and ESBL resistance, and a physician order directed isolation precautions while on antibiotics for ESBL in urine. During observations, an isolation cart and contact precaution signs were posted outside the resident’s room, and CNA A and CNA B were observed exiting the room wearing gowns and gloves but discarding the PPE in the hallway after interacting with other staff. Both CNAs confirmed they had not removed and discarded the PPE before leaving the room, and stated PPE was to be discarded prior to exiting the room for a resident in contact isolation. The facility also failed to ensure Enhanced Barrier Precautions were used for a resident with a Foley catheter. The resident had diagnoses including congestive heart failure, obstructive and reflux uropathy, and benign prostatic hyperplasia, and had a physician order for EBP related to the Foley catheter. During observation, a restorative aide transferred the resident and the urinary catheter bag from the bed to a wheelchair without wearing gloves or a gown, despite the EBP indicator posted outside the room. The aide confirmed she had transferred the resident and catheter bag without PPE and stated she did not think the resident needed gown and gloves. The DON confirmed the resident required contact isolation for ESBL and that staff were to don gown and gloves before entering and doff and discard PPE before exiting the room. The DON also confirmed the resident with the Foley catheter required EBP, including gown and gloves during direct care, and that staff used the triangle with an exclamation point on the door to identify residents requiring EBP. The Director of Clinical Services confirmed that transferring and contact with urinary catheter bags were high-contact resident care activities requiring gown and gloves, and confirmed EBP precautions were not maintained during the transfer.
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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 Cleveland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Cleveland | 3.1 mi | ★★★★★ | 9 | 0 |
| Bradley Health Care & Rehab | 3.6 mi | ★★★★★ | 3 | 0 |
| Signature Healthcare Of Cleveland | 3.9 mi | ★★★★★ | 6 | 0 |
| Life Care Center Of Ooltewah | 10.1 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Collegedale | 10.7 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.