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 maintain dignity through grooming assistance: A resident with dementia, diabetes, and muscle weakness had moderate cognitive impairment and needed partial/moderate help with personal hygiene. Staff confirmed shaving was to be offered on shower days and as needed, but the resident was observed in bed with a large amount of facial hair and had not been shaved, despite expressing interest in having it removed.
Failure to Honor Bathing Preferences: Two residents did not receive the showers they preferred and were scheduled for, and instead were given bed baths without documentation of shower refusal. One resident with fx of the L femur, DM, and muscle weakness stated he had not received a shower since admission, while another resident with dementia, anxiety, muscle weakness, and depression had only received bed baths despite a stated preference for showers. Staff and the DON confirmed showers were to be offered first and refusals documented, but no refusal documentation was found.
An LPN left Medication Cart 1 unlocked and unattended while preparing medications, then confirmed the cart had been left unsecured. Facility policy required drugs and biologicals to be stored in locked compartments with access limited to authorized personnel, and the DON confirmed medication carts should be locked when unattended.
Misappropriation of resident property and medication: A cognitively intact resident with dementia-related diagnoses returned from a hospital stay and found a wallet and ring missing from a room lockbox; a CNA later confessed to taking the wallet and cash. In a separate incident, an LPN found a suspicious narcotic count and missing oxycodone for a resident with severe cognitive impairment and chronic pain; the count sheet had been altered, and the agency nurse involved was later found to have surrendered their license for medication diversion.
A resident with intact cognition and multiple medical diagnoses alleged physical abuse by an LPN, including improper handling during a transfer and use of a lock on the wheelchair. The facility was aware of the allegation the same day, but the LPN continued working while the investigation remained open. Resident interviews and skin assessments were not completed until about a month later, and the DON and Administrator stated the investigation tasks should have been completed within the required 5-day timeframe.
Failure to Submit Timely PASRR After New Mental Health Diagnoses: The facility failed to submit new Level I PASRRs for two residents after new mental health diagnoses were identified. One resident had a new psychotic disorder diagnosis, and another had PTSD documented in the record; both had prior PASRRs, but no updated PASRR was submitted after the new diagnoses were identified. The DON confirmed that a new Level I PASRR should be submitted with any new major mental health diagnosis.
Failure to Maintain Resident Dignity Through Grooming Assistance
Penalty
Summary
The facility failed to provide dignity for one resident, Resident #90, who was admitted with diagnoses including muscle weakness, diabetes, and dementia. A quarterly MDS assessment showed the resident had a BIMS score of 9, indicating moderate cognitive impairment, and required partial/moderate assistance with personal hygiene. The care plan directed staff to assist with ADLs as needed, and the facility policy stated residents unable to carry out ADLs were to receive necessary services to maintain grooming. During an observation and interview, Resident #90 was found lying in bed with a large amount of facial hair on the upper lip and expressed interest in having it removed. The bathing schedule showed the resident was scheduled for showers on Wednesday, Saturday, and PRN, and the resident had received a bed bath two days earlier. CNA A stated shaving was to be offered on shower days and that Resident #90 required assistance with shaving. LPN A confirmed the resident had not been shaved and stated residents were to have facial hair removed on shower days. The DON also confirmed staff were to offer shaving for male and female residents on shower days and as needed, and acknowledged Resident #90 had a large amount of facial hair and had not been shaved.
Failure to Honor Residents’ Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of two residents by providing bed baths instead of the showers they preferred and were scheduled to receive. Resident #73, admitted with diagnoses including fracture of the left femur, diabetes, and muscle weakness, had a care plan for ADL assistance and a Kardex indicating showers on Tuesday and Friday evenings, but the care plan did not reflect the resident’s bathing preference. Review of facility documentation from 6/16/2026 through 7/1/2026 showed no showers were given, and the record contained no documentation that Resident #73 refused showers. During interviews, Resident #73 stated he had not received a shower since admission and had only received bed baths, although his preference was a shower. Resident #106, admitted with diagnoses including dementia, anxiety, muscle weakness, and depression, had a care plan for ADL assistance but no bathing preference documented. The resident’s Kardex indicated showers on Wednesday and Saturday, yet documentation from 5/27/2026 through 6/27/2026 showed only bed baths were provided, including on multiple listed dates, with no showers given per the resident’s preference. The Responsible Party stated Resident #106 had not had a shower in over 30 days and preferred showers. Staff interviews confirmed showers were to be offered first, refusals were to be documented and reported to the nurse, and bed baths were only to be offered if a shower was refused; however, no documentation of shower refusal was found for either resident, and the DON confirmed both residents received bed baths instead of their preferred showers.
Unlocked Medication Cart Left Unattended
Penalty
Summary
Medication storage was not maintained in accordance with facility policy and accepted storage requirements when Medication Cart 1 was left unlocked and unattended. The facility policy titled, Medication Storage, dated 11/28/22, stated that all drugs and biologicals must be stored in locked compartments and that only authorized personnel may have access. During an observation and interview on 6/30/2026 at 7:52 PM, an LPN was preparing medications at the cart, then left the medication cart and entered a resident's room, leaving the cart unlocked and unattended. The LPN later returned and confirmed the cart had been left unlocked and unattended, and stated she should have locked it when leaving. RN A stated there were no wandering residents in the facility, and no wandering residents were observed during the night shift observation. The DON later confirmed medication carts should be locked when left unattended.
Misappropriation of resident property and medication
Penalty
Summary
The facility failed to protect residents from the wrongful use of their belongings and medications. For one resident, who had diagnoses including Alzheimer's disease, dementia, and cognitive communication deficit but had a BIMS score of 15, the resident returned from a hospital stay and discovered a wallet and ring missing from a lockbox in the room. The wallet had contained the resident's driver's license, Social Security card, and about $30 to $40 in cash. The Administrator later interviewed staff and determined a CNA assigned to the resident had taken the wallet, removed the money, and hidden the wallet in the resident's room; the CNA denied taking the ring. The facility reported the theft, notified the resident and ombudsman, and terminated the CNA. For another resident, who had Alzheimer's disease, dementia, chronic pain, and severe cognitive impairment with a BIMS score of 4, the facility had an order for oxycodone 10 mg every four hours as needed for pain. During a narcotic count, an LPN identified that the narcotic tracking sheet appeared suspicious and could not locate the resident's oxycodone on the medication cart. The count sheet showed a number had been altered, with one count scribbled out and another written beside it. The resident requested pain medication, and the nurse was unable to find the resident's medication card on the cart, but was able to access the medication through Cubex and administer it. The investigation found the altered narcotic count occurred on an agency LPN's shift. The Administrator later determined the agency nurse's license had been surrendered months earlier for medication diversion, meaning the individual was not a licensed nurse at the time of working in the facility. The facility documented the discrepancy, contacted the staffing agency, and reported the incident to the state agency and law enforcement.
Failure to Protect Resident After Abuse Allegation and Complete Timely Investigation
Penalty
Summary
The facility failed to immediately implement protective measures after an allegation of staff-to-resident physical abuse involving Resident #94 and failed to complete a timely and thorough investigation. The facility policy stated that abuse allegations must be reported immediately, the resident must be protected first, the alleged perpetrator must be removed from duty pending investigation, and the investigation must be completed within 5 days. The policy also required immediate investigation and corrective action when abuse was reported or observed. Resident #94 was admitted on 12/20/2024 and had diagnoses including cognitive, social, or emotional deficit following other cerebrovascular disease, type 2 diabetes mellitus, and acute kidney failure. A 5-day MDS showed a BIMS score of 15, indicating intact cognition. The allegation involved LPN #4 and Resident #94, with the resident reporting that a silver lock was used to lock the wheelchair and that LPN #4 pushed the resident's hand away during a transfer. The facility became aware of the allegation on 12/24/2024 and reported it later that evening. The resident's emergency contact identified LPN #4 as the alleged perpetrator based on information from the resident. Facility investigation documents showed that resident interviews and four head-to-toe skin assessments were not completed until 01/24/2025, about 30 days after the alleged incident. LPN #4's timecards showed she worked on both 12/23/2024 and 12/24/2024, and she stated that the Administrator informed her of the allegation when she reported to work on 12/24/2024, but she completed her shift while the investigation was ongoing. The DON and Administrator stated that the alleged perpetrator should have been removed from duty and that resident interviews, skin assessments, and staff education should have been completed within the required timeframe, but they could not explain why the investigative tasks were delayed.
Failure to Submit Timely PASRR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a timely Pre-admission Screening and Resident Review (PASRR) after new mental health diagnoses were identified for 2 residents reviewed for PASRR. Facility policy stated that residents requiring Resident Review due to a significant change in status should be identified timely and that an initial Level I screening is performed prior to admission or when a significant change in status occurs. Resident #4 had a prior Level I PASRR showing Anxiety Disorder and Mild or Situational Depression before admission, and the medical record showed admission diagnoses including Anxiety Disorder and Major Depressive Disorder. The record also showed a new diagnosis of Psychotic Disorder with Delusions on 7/4/2025, and later care plan and MDS documentation listed Major Depressive Disorder, Anxiety Disorder, and Psychotic/Delusional Disorder, but no new PASRR was submitted for the new diagnoses. Resident #79 had a prior Level I PASRR listing multiple mental health diagnoses, was admitted with PTSD, and had care plan and MDS documentation reflecting PTSD, but no new PASRR was submitted for that diagnosis. During interview, the DON stated a new Level I PASRR should be submitted with any new major mental health diagnosis and confirmed that neither resident had a new Level I PASRR submitted after the new diagnosis was identified.
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Compliance trends in Tennessee
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 2 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 2-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): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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 Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 2 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 2 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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