Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tennova Lafollette Health And Rehab Center during CMS and state inspections, most recent first.
Inaccurate MDS coding was found for oral/dental status, hospice, and PASRR. One resident was documented as having natural teeth on the MDS despite observations showing several missing upper and lower teeth. Two residents admitted under hospice services had admission MDS assessments that did not code hospice in Section O, and another resident with a PASRR Level II determination had an annual MDS that incorrectly indicated no current Level II PASRR status.
Hand Hygiene Not Followed During Wound Care: A wound care nurse failed to follow proper hand hygiene and glove-changing practices while providing wound care to a resident with a stage 3 heel pressure ulcer. After removing the old dressing and bandage, she cleansed the wound using the same gloves without hand hygiene or changing gloves. The nurse and DON confirmed the infection control lapse, and the facility could not provide a wound care procedure for handwashing and dressing changes.
A facility failed to ensure call lights were within reach for two residents whose care plans directed staff to keep the call light available. Both residents were cognitively intact per BIMS, but each was observed without a bedside call light and reported using a roommate’s call light instead. CNA and LPN staff were unaware the call lights were missing, and the Administrator confirmed the deficiency.
A facility failed to accurately code an MDS assessment for a resident's oral/dental status. The resident, admitted with various diagnoses, was documented as having natural teeth in the MDS assessment, despite being confirmed as edentulous in other assessments and observations. The DON confirmed the inaccuracy.
A facility failed to document post-dialysis assessments for a resident requiring dialysis, as per their policy. The resident, with multiple health conditions including End Stage Renal Disease, was cognitively intact and had a care plan requiring monitoring of the dialysis site. However, from January 1 to January 23, there was no documentation of the dialysis catheter site being assessed for bleeding after treatments. An observation showed the dressing was intact, but the DON confirmed the lack of documentation.
Expired supplies, including IV catheters, nutrition powder, and lab tubes, were found in two of the four medication storage rooms in the facility. RNs confirmed the expiration of these items, and the DON also acknowledged the issue.
A facility failed to include a midline catheter in a comprehensive care plan for a resident with Emphysema, Anxiety Disorder, and Chronic Respiratory Failure. Despite the resident being cognitively intact, the care plan did not address the catheter's placement, observation, and monitoring, as confirmed by the Administrator.
A facility failed to obtain a physician's order for midline IV dressing changes and did not document daily assessments or dressing changes for a resident receiving IV therapy for pneumonia. Despite the lack of documentation, nurse's notes indicated the midline catheter was patent and the dressing was intact. The facility's policy required dressing changes every 7 days, but there was no evidence this was followed.
A CNA performed a blood glucose test without proper training, violating facility policy. An LPN allowed this action, leading to both staff members' termination. The facility's policy required trained personnel for such tasks, which the CNA was not. The incident was confirmed through interviews and an investigation.
A CNA failed to follow infection control practices for a resident under Enhanced Barrier Precautions, making contact without performing hand hygiene or wearing gloves and a gown. The CNA admitted to the oversight, despite prior education on proper procedures.
Inaccurate MDS Coding for Dental Status, Hospice, and PASRR
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for oral/dental status for one resident. The resident was admitted with diagnoses including COPD, GERD, and heart failure, and the admission MDS documented a BIMS score of 15, indicating cognitive intactness. The MDS recorded that the resident did not have no natural teeth or tooth fragments, but an observation on 6/30/2026 showed the resident was missing several upper and lower teeth. During an observation and interview on 7/1/2026, the MDS Coordinator confirmed the resident was missing several upper and lower teeth and acknowledged the oral/dental status on the MDS dated 12/16/2025 was inaccurate. The facility also failed to accurately code hospice status and PASRR status on MDS assessments for three residents. Two residents were admitted under hospice services, as shown by physician orders, nursing admission documentation, and baseline care plans, but their admission MDS assessments did not code hospice care in Section O; one resident had a BIMS score of 3 and the other had a BIMS score of 99, indicating inability to complete the interview. In addition, one resident with diagnoses including major depressive disorder, unspecified psychosis, and epilepsy had a Notice of PASRR Level II Outcome stating the PASRR Level II evaluation remained good during the stay, but the annual MDS coded that the resident was not currently considered by the state Level II PASRR process to have a serious mental illness, intellectual disability, or related condition. The MDS Coordinator confirmed the hospice and PASRR coding was inaccurate.
Hand Hygiene Not Followed During Wound Care
Penalty
Summary
Failure to provide and implement an infection prevention and control program occurred when the wound care nurse did not follow appropriate hand hygiene practices during wound care for a resident with a stage 3 pressure ulcer of the left heel. The resident was admitted and readmitted with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, heart failure, peripheral vascular disease, and a pressure ulcer of the left heel stage 3. The resident’s annual MDS showed a BIMS score of 15, indicating cognitive intactness. Physician orders directed cleansing of the left heel, pat dry, apply treatment, and cover with border foam, and the care plan addressed the stage 3 left heel wound and following treatment orders per MD. During observation of wound care, the wound care nurse sanitized her hands, applied gloves, and removed the resident’s elastic bandage and soiled border foam dressing from the left heel. She then cleansed the wound with wound cleanser and clean gauze using the same gloves, without performing hand hygiene or changing gloves after removing the soiled dressing. She later removed her gloves, performed hand hygiene, applied new gloves, and placed a new dressing. The resident’s left heel showed no signs of infection. The wound care nurse confirmed she failed to follow proper infection control practices, and the DON also confirmed the nurse did not follow infection control practices during the wound care. The facility was unable to provide a wound care procedure related to handwashing and wound dressing change upon request.
Call Lights Not Available at Bedside for Two Residents
Penalty
Summary
The facility failed to ensure a call light was available at the bedside for two residents, both of whom had care plans directing staff to keep the call light within reach and encourage its use for assistance. Resident #63 had diagnoses including unspecified dementia, type 2 diabetes, insomnia, major depressive disorder, and anxiety, and a quarterly MDS assessment showed a BIMS score of 15, indicating the resident was cognitively intact. During an observation and interview, Resident #63 was found without a call light at the bedside and stated it had been gone and that he used his roommate’s call light when he needed staff assistance. A later observation again showed no call light at the bedside. Resident #43 had diagnoses including cerebral palsy, type 2 diabetes, and generalized anxiety disorder, and a quarterly MDS assessment also showed a BIMS score of 15. During an observation and interview, Resident #43 was found without a call light at the bedside and stated it had torn up and that he used his roommate’s call light. Additional observations later that day again showed no call light at the bedside. CNA A, identified as the routine caregiver for both residents, stated she was unaware they did not have call lights at the bedside, and LPN B also stated she was unaware. The Administrator later confirmed the facility failed to ensure both residents had call lights in reach at the bedside.
Inaccurate MDS Assessment for Oral/Dental Status
Penalty
Summary
The facility failed to accurately code a Minimum Data Set (MDS) assessment for the oral/dental status of a resident. According to the CMS Long-Term Care Facility RAI 3.0 User's Manual, the MDS assessment should accurately reflect the resident's status, including dental problems present in the 7-day look-back period. Resident #162, who was admitted with diagnoses including Dementia, Generalized Anxiety, Major Depressive Disorder, and a fracture of the lower end of the right femur, was documented as having natural teeth in the admission MDS assessment dated 1/7/2025. However, a nursing admission baseline health and history assessment dated 12/31/2024, as well as observations on 1/21/2025 and 1/23/2025, confirmed that the resident was edentulous. The Director of Nursing confirmed the inaccuracy of the MDS assessment for the resident's oral/dental status.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to document post-dialysis assessments for a resident who required dialysis services. According to the facility's policy, staff are required to immediately monitor and document the status of a resident's access site upon their return from dialysis treatment to check for bleeding or other complications. However, a review of the nursing progress notes for the resident from January 1, 2025, to January 23, 2025, revealed no documentation indicating that the resident's dialysis catheter site had been assessed or monitored for bleeding after returning from dialysis treatments. The resident in question was admitted with multiple diagnoses, including Major Depressive Disorder, Dependence on Renal Dialysis, Hypertension, Chronic Diastolic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and End Stage Renal Disease. The resident was cognitively intact, as indicated by a score of 15 on the Brief Interview for Mental Status assessment. Despite the facility's comprehensive care plan, which included monitoring the dialysis shunt site for signs of infection, there was a lack of documented assessments. An observation on January 23, 2025, showed the resident's dressing was dry and intact, but the Director of Nursing confirmed that post-dialysis assessments had not been documented as required.
Expired Supplies Found in Medication Storage Rooms
Penalty
Summary
The facility failed to ensure that expired supplies were not available for resident use in two of the four medication storage rooms observed. During an observation of the 2nd floor north medication storage room, it was found that several intravenous (IV) catheters were expired. Registered Nurse (RN) C confirmed the expiration of these IV catheters. Similarly, in the 3rd floor medication storage room, expired nutrition powder packets, lab tubes, and IV catheters were identified. RN A confirmed the expiration of these items. The Director of Nursing (DON) also confirmed the expiration of the nutrition powder, lab tubes, and IV catheters during an interview.
Failure to Develop Comprehensive Care Plan for Midline Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who required a midline catheter. The facility's policy mandates the creation of a comprehensive, person-centered care plan that aligns with the resident's rights, needs, and choices. However, upon review, it was found that the care plan dated 4/18/2024 did not include the midline catheter for the resident. The resident, who was admitted with diagnoses including Emphysema, Anxiety Disorder, and Chronic Respiratory Failure, was cognitively intact as indicated by a BIMS score of 14. During an interview, the Administrator acknowledged that a care plan for the midline catheter placement, observation, and monitoring was not developed, confirming the facility's failure to adhere to its policy.
Failure to Document and Perform Midline IV Dressing Changes
Penalty
Summary
The facility failed to adhere to its policy and CDC guidelines regarding the administration and monitoring of intravenous (IV) therapy for a resident. Specifically, the facility did not obtain a physician's order for dressing changes for a midline IV catheter, did not ensure daily assessments of the midline IV site were completed, and did not document any dressing changes for the resident. The facility's policy required midline dressing changes every 7 days or as needed if the dressing became soiled, loose, or saturated, and to document the procedure and assessment in the electronic medical record. However, there was no documentation of dressing changes or monitoring of the midline catheter in the resident's records. The resident was receiving IV antibiotics and steroids for pneumonia, and the medication administration was documented as ordered. Despite the lack of documentation for dressing changes, nurse's notes indicated that the midline catheter was patent, flushed well, and the dressing was dry and intact on several occasions. Interviews with the physician and infection preventionist revealed that the facility was expected to follow protocol for dressing changes and monitoring, but without a physician's order, there was no documentation of dressing changes. The administrator confirmed that the dressing should be changed every 7 days, but there was no documentation to support that this was done according to policy.
Staff Competency Deficiency in Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure that staff performed tasks within their scope of practice, leading to a deficiency in staff competency. The facility's policy on blood glucose monitoring specified that testing should be performed by trained personnel, which may include licensed nurses and other qualified staff. However, a Certified Nursing Assistant (CNA) was found to have performed a blood glucose test without the necessary training or documentation of competency. This action was against the facility's policy, as CNAs were not trained to perform such tasks. The incident was brought to light when a CNA reported that a Licensed Practical Nurse (LPN) had allowed the CNA to perform a blood glucose test on a resident. An investigation confirmed that the LPN had indeed permitted the CNA to conduct the test while the LPN was present in the room. Both the CNA and the LPN were subsequently terminated for their roles in this incident. Interviews with the facility's Risk/Facility Compliance Officer and the Administrator confirmed that the CNA acted outside of her scope of practice, and the LPN failed to adhere to the facility's policy by allowing this to occur.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to adhere to infection control practices during the care of a resident under Enhanced Barrier Precautions (EBP). The resident, who was admitted with diagnoses including Sepsis, Venous Insufficiency, Type 1 Diabetes Mellitus, and Anxiety Disorder, was cognitively intact and had active diagnoses of Septicemia. The comprehensive care plan required the use of gloves and gowns during high-contact activities, as indicated by the signage on the resident's door. This signage also instructed staff to wash their hands before exiting the room and not to reuse gowns and gloves for multiple residents. During an observation, a Certified Nursing Assistant (CNA) entered the resident's room and made physical contact with the resident before performing hand hygiene or donning gloves and a gown, as required by the EBP guidelines. The CNA later acknowledged the mistake, attributing it to being in a hurry and not thinking, despite having received education on the proper procedures. The Infection Preventionist confirmed that the expectation was for staff to perform hand hygiene and wear gloves and a gown before any physical contact with residents under EBP.
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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 Lafollette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cumberland Village Care | 4.8 mi | ★★★★★ | 0 | 0 |
| Rocky Top Care Center | 9.7 mi | ★★★★★ | 7 | 0 |
| Andersonville Tn Opco Llc | 10.3 mi | ★★★★★ | 8 | 0 |
| The Waters Of Clinton, Llc | 15.3 mi | ★★★★★ | 0 | 0 |
| Beech Tree Health And Rehabilitation | 16.9 mi | ★★★★★ | 2 | 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 October 2026) and official state health department websites.