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 Supervise a Resident with Dementia and Wandering Behaviors: A resident with severe cognitive impairment, high wandering risk, and repeated falls did not have an individualized person-centered behavior plan for wandering or exit-seeking. Video showed the resident moving around the unit, attempting to follow visitors out an exit, entering another resident’s room, and remaining there undetected for about 44 minutes before being found crawling out with forehead bleeding. EMS transported the resident to the hospital, where the bleeding was documented as reinjury of prior sutured lacerations.
Failure to Maintain Resident Dignity During Meal Service: During lunch meal service, meals were served on trays with plates and utensils left on the trays for all observed residents, and one resident who required set up and supervision with eating waited more than 20 minutes while others at the same table received and finished their meals. The resident, who had diagnoses including depression, mild cognitive impairment, anxiety, tremor, malnutrition, and muscle weakness, stated that waiting to be served made him feel left out; the DON confirmed the dignity concern.
Kitchen and equipment were found dirty and unsanitary, including a food processor, electric can opener, toaster, drawer, cutlery tray, reach-in freezer, hanging light fixtures, and HVAC vents/grills with visible debris and crusted buildup. The CNA, CDM, and MD all confirmed the items and surfaces were not clean and sanitary.
Failure to Timely Report Allegations of Resident-to-Resident Abuse: The facility did not report allegations of potential resident-to-resident abuse within the required timeframe for two separate incidents involving four residents. One report was sent 18 hours after the event, and another was not reported until 5 days later, despite the DON confirming the reports were not made within 2 hours of the facility becoming aware of the allegations.
Failure to Revise Care Plans for Skin Changes: The facility did not revise the comprehensive care plans for two residents to reflect changes in skin integrity. One resident had a stage 2 pressure ulcer with physician orders for zinc oxide and heel floating, while the other had scabbed areas, scratches, self-inflicted abrasions, and shearing to the buttocks with related orders for lotion, protective sleeves, and barrier cream. The RN MDS Coordinator confirmed the care plans were not updated to include these skin-related problems and treatments.
A resident with CHF, CKD, and cardiomyopathy, and severe cognitive impairment, was observed receiving oxygen at 3 L/min by nasal cannula without a physician order. The chart showed no oxygen order during the review period, and an LPN confirmed the omission before an order was later obtained.
Failure to Supervise and Individualize Dementia Behavior Care
Penalty
Summary
The facility failed to provide individualized behavioral interventions and sufficient supervision for a resident with dementia, severe cognitive impairment, wandering, and exit-seeking behaviors. The resident was admitted with diagnoses including dementia, bipolar disorder, macular degeneration, repeated falls, and a displaced comminuted fracture of the left tibia. The admission MDS showed a BIMS score of 3, indicating severe cognitive impairment, and the wandering risk assessment identified the resident as high risk for wandering. The resident’s record also documented impaired thought processes and wandering behaviors occurring 4 to 6 days weekly. The resident’s care plan addressed mood-related concerns and psychoactive medication use, but it did not include an individualized person-centered plan to address the resident’s dementia-related wandering, elopement risk factors, or known history of wandering. The record also showed multiple falls after admission, including falls on several dates before the incident in question, and the resident was transferred to an ED after sustaining forehead lacerations and bruising from a prior fall. A psychiatric note described worsening confusion, anxiety, restlessness, agitation in the evenings and at night, and severe cognitive impairment, with the resident oriented to person only. On the day of the incident, video surveillance showed the resident wandering the unit in a wheelchair, approaching the nurse’s station without staff noticing until close proximity, attempting to follow visitors out an exit door, testing doors, and entering another resident’s room. The resident remained in that room for approximately 44 minutes without staff awareness or redirection and was later found crawling out of the room with blood on the forehead. Staff responded after the resident was discovered, and EMS transported the resident to the hospital. Hospital records documented that the forehead bleeding was due to reinjury of previously sutured laceration sites from an earlier fall. The facility later confirmed that it had not developed or implemented a person-centered dementia care plan with specific interventions for the resident’s wandering, exit-seeking, combative behaviors, or frequent falls, and had not adequately supervised or redirected the resident during the incident.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to remove resident plates and utensils from serving trays during lunch meal service, resulting in an undignified dining experience for 8 of 8 residents observed in the [NAME] 1 dining room. During multiple observations on 5/18/2026 and 5/19/2026, meals were served on service trays and the plates and utensils remained on the trays throughout the meal. The facility policy titled, Promoting/Maintaining Resident Dignity, stated that residents are to be treated with respect and dignity and cared for in a manner and environment that maintains or enhances quality of life. The facility also delayed assistance to Resident #13, who was admitted with diagnoses including Adjustment Disorder with Depressed Mood, Mild Cognitive Impairment, Generalized Anxiety, Unspecified Tremor, Moderate Malnutrition, and Muscle Weakness. The resident’s MDS showed a BIMS score of 14, indicating cognitive intactness, and the resident required set up and supervision with eating. During lunch observations, Resident #13 waited more than 20 minutes while other residents at the same table received and finished their meals before staff served and assisted him. During interview, the resident stated that he had frequently watched other residents eat while he waited for assistance and said, "I am real easygoing, but sometimes it makes me feel left out." The DON confirmed the facility failed to maintain the resident’s dignity during meal services.
Kitchen and Equipment Not Maintained in Clean, Sanitary Condition
Penalty
Summary
The facility failed to ensure the kitchen and kitchen equipment were maintained in a clean and sanitary condition in [NAME] House. During observations in the cooking area and kitchen, a small food processor stored in an upper cabinet had splatters of a brown substance on the exterior and on/off button, an electric can opener had white crust-like debris and a thick brownish black substance on the blade, and a toaster stored in a lower cabinet had dry tan crust-like debris in the bottom of the toaster, on the top perimeter, and on the shelf where it was stored. A kitchen drawer beneath the microwave had orange, green, and tan crust-like debris around the front top perimeter and orange crust-like debris inside the drawer, and a cutlery tray containing flatware had white and tan crust-like debris around its inner perimeter. Additional observations showed a reach-in freezer with multiple dried brownish black debris and yellow crust debris under the bottom rack, four hanging light fixtures with grayish white fine dry matter on the outside perimeter, and HVAC return grills and a ceiling vent with grayish brown fine dry matter covering them. The Certified Nursing Assistant confirmed the items and surfaces were not in a clean and sanitary condition and needed to be cleaned. The Certified Dietary Manager also confirmed the food processor, toaster, reach-in freezer, cutlery tray, hanging light fixtures, kitchen drawer, and shelf in the cabinet needed to be cleaned, and stated the kitchen condition was not clean and sanitary. The Maintenance Director stated maintenance was responsible for cleaning the HVAC return grills and vents as needed and had no specific cleaning schedule for them, and confirmed the kitchen HVAC return grill and vent were not in a clean and sanitary condition.
Failure to Timely Report Allegations of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure facility reported incidents related to allegations of abuse were reported within the required time frame for 4 residents. Review of the facility abuse policy stated that suspected resident abuse, mistreatment, or neglect must be reported per regulation to the Department of Health by the Administrator or designee, and that immediate reports should be given to Administration when abuse is witnessed or known. The deficiency involved allegations of potential resident-to-resident abuse between Residents #1 and #2 and between Residents #3 and #4. Review of the incident records showed that one allegation involving Residents #1 and #2 occurred on the evening of 4/28/2026 around 7:50 PM, but the state agency did not receive the report until 4/29/2026 at 2:01 PM, 18 hours later. Another incident involving Residents #3 and #4 occurred on the evening of 4/23/2026, but the abuse coordinator was not made aware until the morning of 4/24/2026, when the facility began its investigation, and the report was not sent to the state agency until 5 days later. During interview, the DON confirmed the facility failed to report the allegations of potential resident-on-resident abuse to the state agency within 2 hours of becoming aware of them, as required by state and federal requirements.
Failure to Revise Care Plans for Skin Integrity Changes
Penalty
Summary
The facility failed to revise the comprehensive care plan to include changes in skin integrity for 2 residents reviewed. Facility policy titled, Patient Care Policies, stated that physicians’ orders are to be incorporated into the care plan. Resident #40 was admitted with diagnoses including fracture of the left femur, pressure ulcer of the right buttocks stage 2, and anxiety. A 5-day MDS assessment showed a BIMS score of 15 and identified a stage 2 pressure ulcer. The comprehensive care plan dated 5/4/2026 included a skin/wound area, but a physician’s order dated 4/28/2026 directed application of zinc oxide to an open wound and floating heels, and the RN MDS Coordinator confirmed during interview that the care plan had not been revised to include the stage 2 wound, zinc oxide treatment, or floating heels. Resident #64 was admitted with diagnoses including chronic kidney disease with heart failure, type II diabetes mellitus with polyneuropathy, and excoriation disorder. Admission observation documented scabbed areas to both arms and legs, numerous scratches to the bilateral upper extremities, and blanchable redness to the buttocks. The comprehensive care plan dated 8/15/2025, revised 5/13/2026, stated the resident would have no skin breakdown and did not identify specific skin-related problems. Physician orders included Calm-Cool lotion to the upper extremities twice daily and protective sleeves to prevent picking, and a weekly skin observation documented shearing to bilateral buttocks and open abrasions to bilateral arms. A later physician order directed barrier cream to the bilateral buttocks and surrounding area twice daily, and the RN MDS Coordinator confirmed the care plan had not been revised to include the self-inflicted abrasions on both arms or the shearing to the bilateral buttocks.
Failure to Obtain Physician Order for Supplemental Oxygen
Penalty
Summary
The facility failed to obtain a physician’s order for supplemental oxygen for one resident who was observed receiving oxygen at 3 liters per minute by nasal cannula. The resident had diagnoses including hypertensive heart and chronic kidney disease with heart failure, chronic systolic congestive heart failure, chronic kidney disease stage 3A, and cardiomyopathy, and a 5-day MDS assessment showed a BIMS score of 00, indicating severe cognitive impairment. During observations, the resident was lying in bed with supplemental oxygen in use on two separate occasions. Review of the current physician’s orders report showed no order for oxygen during that period. When the resident was observed receiving oxygen, an LPN confirmed there was no physician’s order for it. A physician’s order for oxygen at 3 liters per minute by nasal cannula was then obtained after the surveyor interview, and the DON confirmed that an order should have been obtained to administer oxygen for the resident.
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Compliance trends in Tennessee
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 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): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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 May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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).
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