Citations in Tennessee
Statistics, citations and compliance trends for long-term care facilities in Tennessee.
Statistics for Tennessee (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Tennessee
Failure to provide involuntary discharge appeal notice: A resident with psychosis, schizoaffective disorder, epilepsy, TBI, dementia, and severe cognitive impairment was sent to the ED for psychiatric evaluation after escalating agitation and behavioral disturbances. The facility issued an involuntary transfer/discharge form stating it could not meet the resident’s needs and that the resident was unsafe for others, but there was no resident or RP signature, and the RP later said she was not told she could appeal or that the facility would not take the resident back.
Failure to protect residents from resident-to-resident physical abuse occurred when one resident with dementia-related diagnoses and agitation was involved in two separate altercations with other residents. In one event, the resident reportedly grabbed and twisted another resident’s wrist; in a later event, the same resident allegedly slapped another resident on the arm and face. Staff did not witness either altercation, and both affected residents were assessed with no visible injuries noted.
A resident who was cognitively intact, full code, and dependent on staff for incontinence care developed an acute change in condition with lethargy, speech changes, and decreased responsiveness. Staff did not complete a timely nursing assessment, obtain updated VS, notify the MD and family right away, or transfer the resident promptly; the resident was later diagnosed with an acute CVA and carotid stenosis. Records also showed missed/limited incontinent care, and hospital findings included sperm in the urine plus vaginal and thigh trauma.
A resident with full code status and an acute change in condition became nonverbal and lethargic, but staff did not complete a timely assessment, document the change, or notify the provider immediately. 911 was not called right away, and the resident was transferred to the ER hours later by ambulance. EMS identified a bruise on the resident’s cheek that facility staff had not documented, and the MD confirmed the transfer should have been emergent.
Failure to report an alleged staff-to-resident abuse incident involving a resident with stroke, dementia, depression, and severe cognitive impairment. A nurse heard a CNA and the resident arguing, then found the resident agitated and stating the CNA had hit her in the eye. The DON and ADM confirmed the allegation was not reported to the State or other officials, even though an investigation was started and the allegation was later found unsubstantiated.
Nebulizer masks for two residents were found uncovered and open to air on bedside tables instead of being stored per facility policy in a plastic bag labeled with the resident's name and date. One resident had COPD, dementia, and asthma with nebulizer orders for Albuterol and Budesonide, and the other had Myasthenia Gravis and Dysphagia with an Albuterol nebulizer order. The DON confirmed the masks were not stored properly.
Failure to Provide Involuntary Discharge Appeal Notice
Penalty
Summary
The facility failed to provide notification of involuntary discharge that included information about the resident’s right to appeal for one resident reviewed for admission, transfer, and discharge. The facility policy stated that transfer/discharge notices must be provided in a language and manner the resident and representative can understand and must include appeal rights and state contact information. The policy also stated the notice must generally be provided at least 30 days before transfer or discharge, with exceptions for certain urgent circumstances. Resident #29 was admitted with diagnoses including psychosis, schizoaffective disorder, anxiety, epilepsy, traumatic brain injury, and dementia. The record showed a significant change MDS with a Brief Interview for Mental Status score of 00, indicating severe cognitive impairment, along with daily behaviors toward self, dependence on staff for ADLs, and use of antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. On 7/6/2026, the physician ordered the resident sent to the ED for immediate evaluation due to increased agitation and escalating behavioral disturbances that presented an immediate risk of harm to herself and others, and the resident was transferred to the ER for a psychiatric evaluation. The Nursing Home Notice of Involuntary Transfer or Discharge form dated 7/6/2026 listed reasons for discharge or transfer, including that the nursing home could not care for the resident and that the resident made the nursing home unsafe for other people. The form was signed by the Administrator and Medical Director, but there was no signature from the resident or responsible party. The resident’s responsible party later stated she was unaware she could appeal and reported that the facility did not tell her it would not take the resident back. During interview, the Administrator stated the responsible party was contacted, the situation was explained, and the notice was mailed, but the facility was unable to provide a signed copy of the notice showing that appeal information had been provided.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse during resident-to-resident altercations involving a resident with diagnoses including vascular dementia with psychotic disturbance, generalized anxiety disorder, restlessness/agitation, and another resident with dementia and severe cognitive impairment. The facility’s abuse policy prohibited physical abuse, including hitting, slapping, and punching. Survey review identified two separate incidents in which the same resident was involved in physical aggression toward other residents. In the first incident, a resident reported that his roommate grabbed and twisted his left wrist after the two were having words. Staff separated the residents, assessed the resident’s wrist and hand, and found no bruising, redness, deformity, or pain. An x-ray later showed no acute fracture or dislocation. Interviews with CNA and LPN staff indicated they did not witness the altercation, but they were informed of the allegation after it occurred. The resident who was alleged to have grabbed the wrist was placed on 1:1 observation and moved to a private room. Staff stated they had not observed prior physical altercations involving that resident before the incident. In the second incident, another resident reported that the same roommate was verbally and physically aggressive, stating the roommate came to his side of the curtain, told him to get out, and then slapped him on the arm and across the face. A CNA overheard the argument, heard the resident report being slapped, removed the alleged aggressor from the room, and reported the altercation to the charge nurse, who was the DON that evening. The resident was assessed and no injuries were observed, and he declined hospital evaluation, stating he was okay. The DON and other interviewed staff stated the alleged aggressor was removed immediately, sent to the ER, returned within hours, and placed in a private room. The Behavioral Health PA stated the resident’s moods and behaviors had stabilized after medication changes and that the facility could not have foreseen the second incident because there had been no further agitation or aggression after the earlier event.
Failure to Respond Timely to Acute Change in Condition and Provide Needed Care
Penalty
Summary
The facility failed to protect a cognitively intact, full-code resident from neglect when the resident developed an acute change in condition and the facility did not respond with timely assessment, notification, or transfer. The resident was found with lethargy, changes in speech, gurgling respirations, and later became unresponsive to verbal and tactile stimulation. Although the change in condition was noted in the morning, the record showed no nursing assessment, vital signs, or neurological assessment until about 4 hours later, and the physician and family were not notified at the time the change was first observed. The resident had a history of bladder and bowel incontinence, impaired mobility, and moisture associated skin damage to the right gluteus. The care plan called for toileting assistance, peri-care after each incontinent episode, barrier cream, and turning and repositioning. The record showed the resident was not provided incontinent care every 2 hours or as needed; on the day of the event, incontinent care was documented only twice before the resident left the facility. Staff interviews also indicated the resident was alert and oriented earlier in the day, then became difficult to arouse and different from baseline later that morning. The resident was transferred to the emergency room several hours after the change in condition and was diagnosed with an acute CVA and carotid artery stenosis. Hospital records later showed sperm in the urine, and a forensic exam identified bruising on the inner thigh and a tear on the lower vagina. Interviews with facility and hospital staff confirmed the delayed response to the resident's altered mental status, the lack of timely physician notification, and the absence of current assessment data on the transfer form. The facility was cited for failure to use its resources effectively to maintain the resident's well-being and to ensure the environment was free of neglect.
Delayed Assessment and Emergency Transfer During Acute Change in Condition
Penalty
Summary
The facility failed to provide timely assessment, notification, and emergency transfer for a resident who had an acute change in condition and altered mental status. The resident was cognitively intact on admission, had full code status, and was admitted for rehabilitation after hospitalization for hypertension, a right pubic fracture, osteoarthritis, and overactive bladder. On the morning of the event, staff observed that the resident became less talkative and then nonverbal, with a dazed appearance and altered mental status. Staff interviews showed that the change in condition was recognized, but the resident was not assessed with a head-to-toe evaluation at the time the change was identified, and the physician or NP was not notified immediately. The resident was not transferred to the hospital until approximately 5 hours after the change in condition was first noted. Staff interviews confirmed that 911 was not called immediately and that an ambulance service was used instead. The licensed nurse who saw the resident later stated she did not complete a full assessment and used earlier vital signs rather than obtaining a new assessment. The unit manager also confirmed she did not assess or document the resident’s change in condition and stated she should have called 911. The medical director confirmed that the change in condition and nursing assessments should have been accurately performed and documented, that the physician and NP should have been notified immediately, and that 911 should have been used for the transfer. During the transfer to the hospital, EMS personnel identified a contusion to the resident’s right cheek that facility staff had not documented or recognized. The facility administrator and regional clinical leadership stated the bruise was not known to them until several days after the transfer and acknowledged that if the bruise had been present it should have been documented. The hospital record showed the resident arrived with bruising to the right side of the face after a fall, and the survey findings concluded that the facility failed to provide care and services in accordance with professional standards of practice for timely assessment and emergency transfer during the resident’s acute change in condition.
Failure to Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse involving one resident. The resident had diagnoses including stroke, dementia, and depression, and a quarterly MDS assessment showed a BIMS score of 5, indicating severe cognitive impairment. According to the nurse’s note, a nurse heard a CNA and the resident arguing around 4:00 AM, then found the resident agitated, holding the CNA’s arm, and stating that the CNA had hit her in the eye and that she wanted the CNA out of the room. The resident was assisted with care, had no bruising noted on initial examination, and was monitored for delayed bruising. The DON stated she was aware of the allegation of abuse but confirmed it was not reported to the state or other officials. The Administrator stated he was notified of the allegation, an investigation was started, and the allegation was found unsubstantiated, but he also confirmed it was not reported to the State or any other officials. The RN who witnessed the event stated she recalled the allegation and reported it to her supervisor.
Nebulizer masks left uncovered and not stored properly
Penalty
Summary
The facility failed to ensure respiratory equipment was stored properly for 2 residents reviewed for respiratory care. Facility policy titled, Medication Administration Nebulizers [Updraft], dated 1/2023, required nebulizers to be stored in a plastic bag with the resident's name and date on it. For Resident #51, the medical record showed diagnoses including COPD, dementia, and asthma, with physician orders for Albuterol Sulfate Solution via nebulizer as needed and Budesonide Suspension via nebulization twice daily. The resident's care plan addressed asthma and medication administration as ordered, and the MDS indicated severe cognitive impairment. The MAR showed the resident received breathing treatments as ordered. During observation on 7/20/2026 at 11:13 AM, Resident #51's nebulizer mask was uncovered, open to air, and laying on top of the bedside table. For Resident #89, the medical record showed diagnoses of Myasthenia Gravis and Dysphagia, with an order for Albuterol Sulfate Solution via nebulizer three times a day. The resident's MDS indicated cognitive intactness, the care plan addressed medications as ordered, and the MAR showed breathing treatments were received as ordered. During observation on 7/20/2026 at 10:54 AM, Resident #89's nebulizer mask was also uncovered, open to air, and laying on top of the bedside table. The DON confirmed on 7/21/2026 at 8:09 AM that the nebulizer masks for both residents were not stored properly.
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Compliance trends in Tennessee
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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