Citations in Tennessee
Comprehensive analysis of citations, statistics, 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
Two residents with severe cognitive impairment and complex medical conditions experienced significant weight loss, but recommended nutritional interventions from the RD were not communicated to or implemented by clinical staff. The DON and NP were unaware of the recommendations, and the facility failed to ensure timely follow-up, resulting in actual harm due to unmet nutritional needs.
The facility did not maintain an adequate emergency water supply as required by its policy, with only a 3-day supply of bottled water for drinking and cooking and two out of four hot water heaters not operational. The Administrator confirmed there was not enough water to meet the needs of all residents and staff for a 3-day emergency period.
The facility did not maintain a qualified Dietary Manager as required, leaving the kitchen without appropriate supervision after the previous DM resigned. Staff interviews revealed confusion about who was in charge, with a CNA and a cook temporarily filling supervisory roles despite lacking the necessary credentials. The Registered Dietician only visited twice monthly and was not managing the kitchen, resulting in noncompliance with staffing regulations.
Medications were found unsecured in the bathrooms of two residents who required staff assistance, and a medication cart was left unlocked and unattended during administration. Additionally, temperature logs for medication refrigerators on two halls were incomplete, with multiple dates missing required entries. The DON confirmed these practices did not follow facility policy.
Staff failed to perform hand hygiene between assisting multiple residents during meal service, including handling food and straws with bare hands, and did not properly store soiled linens, leaving them on the floor in a resident's room. These actions were not in accordance with facility infection control policies, as confirmed by staff and the DON.
Staff failed to maintain resident dignity during dining by addressing a resident with inappropriate endearments and serving meals in the hallway to three residents without care-planned preferences. The affected residents had significant cognitive impairments and required assistance, and staff interviews confirmed these actions were not in line with facility policy.
The facility did not provide written information on how to formulate an advance directive to several residents, as required by policy. Medical record reviews and staff interviews confirmed that neither residents nor their responsible parties received the necessary documentation, affecting individuals with a range of cognitive and medical conditions.
The facility did not timely update care plans for two residents after significant changes in their conditions or treatments. One resident's care plan was not revised promptly after a fall, and another resident's care plan was not updated to reflect discontinued diuretic and psychotropic medications, despite these changes being known to staff.
A resident with moderate cognitive impairment reported missing money from her nightstand on multiple occasions, but the allegation was not reported to State or local agencies as required by facility policy. Staff confusion and lack of communication led to the failure to follow mandated reporting procedures for suspected misappropriation of resident property.
Unsecured disposable razors and cleaning chemicals were found in the rooms of several residents, including those with cognitive impairment and physical dependency. Despite facility policies requiring immediate disposal of sharps and removal of hazardous items, these items were left unattended on bathroom sinks. RNs and the DON confirmed that such items should not be left unsecured.
Failure to Implement Dietician Recommendations for Residents with Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for two residents who experienced significant weight loss. Policy review showed that the facility was required to monitor weight changes and implement, monitor, and modify interventions as needed. For both residents, the Registered Dietician identified significant weight loss and recommended the addition of house supplements twice daily. However, these recommendations were not communicated to or implemented by the appropriate clinical staff. The Nurse Practitioner confirmed she was not made aware of the recommendations, and the DON acknowledged that the process for reviewing and acting on dietary recommendations was not followed due to staff absence and lack of follow-up. Both residents involved had complex medical histories, including severe cognitive impairment, dementia, and conditions such as aphasia, Parkinson's Disease, and adult failure to thrive. Despite documented weight loss—nearly 10% for one resident and over 5% for the other—there was no evidence that the recommended nutritional interventions were ordered or provided. The failure to implement these interventions resulted in actual harm to the residents, as the facility did not ensure their nutritional needs were met according to policy and clinical assessment.
Insufficient Emergency Water Supply Maintained
Penalty
Summary
The facility failed to ensure a sufficient emergency water supply was available for all 76 residents, as required by its own policy. The policy specified the amount of water needed for drinking, handwashing, cooking, toilet flushing, and miscellaneous uses, based on the number of residents and staff. During observation and interviews, it was found that only a 3-day supply of bottled water for drinking and cooking was maintained by the Dietary Manager. Additionally, in the boiler room, two out of four hot water heaters, each with a capacity of 116 gallons, were not operational, with one having its front panel missing and both turned off. The Business Office Manager confirmed the limited operational capacity, and the Administrator acknowledged that the facility did not have enough water to maintain a 3-day emergency supply for the average number of 52 employees and all residents.
Failure to Maintain Qualified Dietary Management Staff
Penalty
Summary
The facility failed to employ sufficient and qualified dietary staff to manage the food and nutrition service for all 76 residents. The job description for the Director of Food Services requires a graduate of an accredited dietetic program, at least five years of supervisory experience in a medical facility, and registration as a Food Service Director in the state. However, interviews and observations revealed that the facility did not have a Dietary Manager (DM) at the time of the survey, as the previous DM had quit approximately two weeks prior. Staff interviews indicated confusion and lack of clarity regarding who was supervising the kitchen, with a Certified Nursing Assistant (CNA) temporarily called in to fill the DM role, but also being assigned to CNA duties on the resident care floor. Further interviews with dietary staff, the Registered Dietician (RD), and the Administrator confirmed that the kitchen was being supervised by a cook, who did not hold the required qualifications for the DM position. The RD only visited the facility twice a month and was not managing the kitchen. The Administrator acknowledged that there was no current DM, and the cook was acting as the supervisor. This lack of qualified dietary management resulted in the facility not meeting regulatory requirements for food and nutrition service staffing.
Medication Storage and Security Deficiencies
Penalty
Summary
Facility staff failed to ensure proper storage and security of medications in several instances. Medications were found unsecured in the bathrooms of two residents, both of whom were cognitively intact but required staff assistance for activities of daily living. The medications observed included nasal spray, eye drops, cough syrup, ointment, antifungal cream, and zinc oxide cream. Additionally, a medication cart on one hall was left unlocked and unattended during medication administration. Further deficiencies were identified in the monitoring of medication refrigerator temperatures. Temperature logs for medication refrigerators on two separate halls were found to have multiple dates with missing entries, indicating that daily temperature checks were not consistently performed as required by facility policy. The Director of Nursing confirmed that these practices did not comply with facility protocols for medication security and storage.
Failure to Maintain Infection Control During Dining and Linen Handling
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as evidenced by staff not performing hand hygiene during meal service and improper storage of soiled linens. Specifically, a Certified Nursing Assistant (CNA) was observed assisting multiple residents with meal tray setup, including handling food items and straws with bare hands, and did not perform hand hygiene between resident interactions or before handling additional meal trays. These actions were observed during several consecutive resident meal setups, contrary to the facility's hand hygiene policy, which requires staff to clean their hands between resident contacts and after handling potentially contaminated items. Additionally, soiled linens and clothing were observed left on the floor in a resident's room at multiple times throughout the day. The resident involved had severe cognitive impairment and required assistance with activities of daily living. Facility policy states that soiled linens should be collected at the point of use and placed in a designated receptacle, and should not be left on the floor or in the resident's room. Staff interviews confirmed that these practices were not followed, and the Director of Nursing acknowledged that both hand hygiene and proper linen handling procedures were not maintained.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to maintain resident dignity and respect during dining, as evidenced by staff not using courtesy titles and serving meals in the hallway without care planning for such preferences. Specifically, a registered nurse addressed a moderately cognitively impaired resident using terms such as "honey," "baby," and "babydoll" during meal service, contrary to facility policy which requires the use of courtesy titles and prohibits the use of endearments. Additionally, certified nursing assistants served meals to three severely cognitively impaired residents in the hallway while they were seated in Geri-chairs or Broda chairs, despite none of these residents having care plans indicating a preference for hallway dining. Medical record reviews confirmed that the affected residents had significant cognitive impairments and required staff assistance for activities of daily living, including eating. Observations documented that meals were provided and assistance was given in the hallway rather than in designated dining areas or according to resident preference. Interviews with facility staff, including the RN, MDS Coordinator, and DON, confirmed that serving meals in the hallway without care planning and failing to use appropriate forms of address were not in accordance with facility policy or resident rights.
Failure to Provide Written Information on Advance Directives
Penalty
Summary
The facility failed to provide written information on how to formulate an advance directive to 9 out of 24 sampled residents. Policy review indicated that the Admissions Director or designee is responsible for providing this information prior to or upon admission. However, medical record reviews for multiple residents with various diagnoses, including chronic illnesses and cognitive impairments, showed no documentation that either the residents or their responsible parties received the required written information regarding advance directives. Interviews with facility staff confirmed the deficiency. The Administrator acknowledged the facility's responsibility to provide written documentation on advance directives, and the Social Services Director stated that there was no current process in place to ensure residents received this information. The lack of documentation and process affected residents with a range of cognitive abilities, from cognitively intact to severely impaired, and included those with significant medical conditions such as COPD, heart failure, diabetes, and cancer.
Failure to Timely Update Care Plans After Significant Changes
Penalty
Summary
The facility failed to update or revise care plans for two residents following significant changes in their conditions or treatments. For one resident with a history of bipolar disorder, lower back pain, and vertebral fractures, the care plan was not updated in a timely manner after a fall incident. The fall occurred on 8/8/2025, but the care plan was not revised to include new interventions until 9/3/2025. The MDS Coordinator confirmed that interventions should have been added the next working day, but this did not occur. For another resident with anxiety, delusions, depression, and dementia, the care plan continued to include interventions related to diuretic and psychotropic medications even after these medications had been discontinued as of 7/16/2025. The care plan was not revised to reflect this significant change in the resident's medication regimen. The MDS Coordinator confirmed that the care plan should have been updated to reflect the discontinuation of these medications.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that allegations of misappropriation of resident property were reported in accordance with its own policy and regulatory requirements. Specifically, a resident with moderate cognitive impairment reported missing money from the top drawer of her nightstand, both in her current and previous rooms. The resident was unable to specify the exact amount or date the money went missing, but stated it was mostly loose one-dollar bills. The allegation was brought to the attention of the Administrator, who was also the Abuse Coordinator, but there was confusion among staff regarding who was handling the report, and the Social Services Director was not aware of the specific allegation. Despite the facility's policy requiring immediate reporting of any misappropriation of resident property to the State Regulatory Agency within 24 hours, the allegation was not reported to State and local agencies. Interviews with the resident's nephew confirmed that the resident had reported missing money on multiple occasions, but he had not informed staff. The Administrator and Social Services Director demonstrated a lack of communication and follow-through, resulting in the failure to report the incident as required.
Unsecured Sharps and Chemicals Found in Resident Rooms
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by allowing unsecured sharps and cleaning chemicals to be present in the rooms of five sampled residents. Policy review indicated that contaminated sharps should be immediately discarded into designated containers, and items posing risks to residents' health and safety should be confiscated if found in plain view. Despite these policies, observations revealed that disposable razors and cleaning chemicals were left unsecured in resident bathrooms. Registered nurses confirmed during interviews that these items should not have been left unattended or unsecured in resident rooms. The residents involved had varying degrees of cognitive impairment and physical dependency, including diagnoses such as dementia, depression, hypertension, heart failure, and respiratory conditions. Some residents required moderate to total assistance with activities of daily living. The unsecured items included disposable razors, aerosol air freshener, disinfectant spray, and surface cleaner, all found on or under bathroom sinks. The Director of Nursing confirmed that these items should not have been left unsecure and unattended in residents' rooms.
Some of the Latest Corrective Actions taken by Facilities in Tennessee
- Implemented ongoing Fall, Care plan, Kardex, and Policy audits with concurrent staff education on two-person assist procedures (J - F0689 - TN)
- Established daily fall monitoring to identify trends and adjust interventions promptly (J - F0689 - TN)
- Maintained continuous updates of care plans and Kardexes to reflect current two-person assist requirements (J - F0689 - TN)
- Maintained ongoing competencies and return-demonstration training on resident positioning and repositioning (J - F0689 - TN)
- Measured education effectiveness through daily fall tracking and skills observation (J - F0689 - TN)
- Continued a Quality Assurance Plan for ongoing oversight of the Fall Prevention Program, Resident Safety, and Repositioning practices (J - F0689 - TN)
- Conducted comprehensive facility-wide in-service training on Fall Prevention, Safety and Supervision, and Repositioning for all nursing and respiratory staff, including agency and LOA personnel (J - F0689 - TN)
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents who required assistance with mobility and activities of daily living. In the first incident, a non-verbal, cognitively impaired resident who was totally dependent on staff for mobility and required two-person assistance with bed mobility was being repositioned by two CNAs. One CNA left the room to retrieve additional supplies, leaving the other CNA alone with the resident, who was still positioned on her side. The resident's weight shifted, causing her to fall from the bed and sustain a significant head injury, resulting in a traumatic brain injury and hospitalization. Both CNAs and facility leadership confirmed that the resident was known to require two-person assistance and that the policy was not followed when one CNA left the room during care. In the second incident, another resident with moderate cognitive impairment, Parkinson's disease, muscle weakness, and a history of repeated falls was found on the floor after an unwitnessed fall. The resident complained of severe pain and inability to move her right leg, and requested an x-ray. Staff assisted the resident to bed and then used a mechanical lift to transfer her to a wheelchair, despite her complaints of pain and immobility. There was a delay of over six hours before emergency transport was called to take the resident to the hospital, where she was diagnosed with a displaced subcapital right femoral neck fracture. Interviews revealed that staff did not immediately call 911 and moved the resident despite her symptoms, contrary to expected protocol. The facility's policies required two-person assistance for certain residents and outlined procedures for responding to falls and pain management. However, in both cases, staff failed to follow these protocols, resulting in significant harm to the residents. The incidents were confirmed through medical record review, staff and family interviews, and facility investigations, and led to the identification of Immediate Jeopardy due to the serious injuries sustained by the residents.
Removal Plan
- Educated CNA A and CNA B on 2-person assist with bed mobility and positioning and repositioning the resident while providing care.
- Reviewed all falls, policies, Kardex's and care plans to align with each resident's current bed mobility needs.
- Began in-servicing on Fall Management Program, Safety and Supervision of the Resident, and Positioning and Repositioning of the resident for all licensed Nurses, CNAs, and Respiratory Therapist.
- Implemented Fall audits, Care plan audits, Kardex audits, Policy audits, and on-going education with Licensed Nurses, CNAs, and Respiratory Therapist on 2-person assist with bed mobility to call for help and not leave the room if they need any supplies.
- Conducted skills competency with positioning and repositioning residents with return demonstration to prevent recurrence.
- Monitoring all falls daily.
- Ensuring all care plans and Kardex's are up to date.
- Ongoing competencies and education to ensure training is effective.
- Measuring effectiveness of the in-services by monitoring the falls on a daily basis and observing return demonstrations through competency.
- Conducted a facility wide fall audit with no major injuries.
- Conducted a facility wide care plan audit to ensure any resident that is a 2-person assist reflects accurately and was found to be up to date.
- Conducted a facility wide Kardex audit to ensure all residents had an up-to-date Kardex and aligning with current care plan with 2-person assist with bed mobility.
- Reviewed policies on Fall Prevention Program, Safety and Supervision of Residents, and Repositioning by the Administrator and Director of Nursing with no revisions needed.
- In-serviced all licensed Nurses, CNAs, Respiratory Therapist, any nursing agency personnel and any Nurses, CNAs, Respiratory Therapist on Leave of Absence (LOA) on Fall Prevention, Safety and Supervision of Residents, and Repositioning.
- Continuing ongoing Quality Assurance Plan to monitor facility performance and compliance with the Fall Prevention Program, Safety and Supervision of Residents, and Repositioning by continuing to monitor falls daily and implementing planned interventions and approaches appropriately.
Failure to Provide Appropriate Pain Management Resulting in Actual Harm
Penalty
Summary
The facility failed to provide appropriate pain management consistent with professional standards of practice for two residents who required such services. One resident, who was severely cognitively impaired and dependent on staff for all care, was readmitted after a right below-the-knee amputation. Upon admission, this resident's pain was assessed as moderate to severe, and physician orders included Hydrocodone for moderate pain and Ibuprofen for mild pain. Despite these orders, the facility did not administer Hydrocodone as needed for pain, resulting in the resident experiencing uncontrolled pain, as evidenced by restlessness, trembling, and new behaviors such as attempting to climb out of bed. The resident subsequently sustained an unwitnessed fall with a head injury, leading to hospitalization and diagnosis of subarachnoid hemorrhage and a periorbital fracture. The facility lacked a system to assess and address pain in residents with cognitive impairment, and there was no documentation of pain management interventions in the care plan. Another resident, also with severe cognitive impairment and dependent on staff, sustained an unwitnessed fall. Later, the resident exhibited intense pain through verbal complaints and nonverbal cues such as hollering, grimacing, and guarding the right hip and femur. The practitioner was not immediately notified, and the resident did not receive pain medication. A STAT x-ray was ordered and obtained hours later, revealing a periprosthetic fracture. The resident was transferred to the hospital without having received pain medication prior to transfer. Documentation did not reflect administration of pain medication, and staff interviews confirmed that pain management was not provided during the period of distress. Interviews with staff and review of records revealed multiple failures, including lack of follow-up when pain medications were not available, inadequate pain assessment for cognitively impaired residents, and insufficient documentation of pain management. Staff were aware that pain medications were not delivered or available, but did not take appropriate steps to resolve the issue or utilize available emergency supplies. The facility's policies required documentation and communication regarding pain management, but these were not followed, resulting in actual harm to both residents.
Removal Plan
- Root Cause Analysis was completed.
- Facility-wide audit of all residents with pain medication orders included confirmation the ordered pain medication was available on-site.
- Order request was sent to the pharmacy for a resident needing a re-fill of pain medication; resident received medication from the E-kit until the re-fill arrived.
- Pain Assessment/Management In-service training records were reviewed, including sign-in sheets and cross-referenced with current nursing staff including agency nursing.
- All nurses currently working had received pain assessment and management in-service training.
- Nursing staff were interviewed to describe the training received related to pain assessment, monitoring, and management.
- Training was conducted in person as well as electronically via the online training software.
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