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 significant medical conditions were found to have personal fans in their rooms that were not maintained in a clean and sanitary condition, with visible dust and debris on the blades and grilles. Facility policy required daily cleaning of rooms and equipment, but observations and staff interviews confirmed this was not done for the fans.
An LPN diverted narcotic medication by signing out extra doses of Hydrocodone-Acetaminophen for a resident without a physician order and taking the medication for personal use. The resident received all scheduled doses and did not experience harm, but the facility failed to prevent the misappropriation, resulting in a deficiency under F-602.
A nurse administered medications intended for another resident to a cognitively intact individual with multiple chronic conditions, failing to verify identity or medication details as required by policy. The error was not recognized until the resident developed severe hypotension and required hospitalization. The incident was caused by distraction and failure to follow established medication administration protocols.
The facility did not report multiple incidents of unexplained injuries—including skin tears, hematomas, abrasions, and discolorations—affecting several cognitively impaired residents, as required by policy and state regulations. Despite documentation of these injuries and internal notifications, the incidents were not reported to the state agency, and the Administrator confirmed that such reporting did not occur.
The facility did not conduct or document required investigations for injuries of unknown origin in six residents with cognitive impairment and multiple comorbidities. Despite policy requiring thorough investigation of incidents such as skin tears, hematomas, and abrasions, the facility was unable to provide investigation records for these events. Interviews with the DON and Administrator confirmed that investigations were not routinely performed or documented, resulting in a deficiency.
The facility did not consistently record daily temperatures for the refrigerator, freezer, and cooler as required by policy, resulting in food being stored and served without proper temperature monitoring. This deficiency affected 38 residents who received food trays during the period when temperature checks were not documented.
The facility did not properly track infections by organism or monitor for outbreaks, and failed to implement Enhanced Barrier Precautions for a resident with wounds. Staff did not post required signage or use appropriate PPE during wound care, despite facility policy and physician orders. Interviews confirmed that infection control protocols were not followed.
The facility did not hold or document required care plan meetings on admission and quarterly for two residents with significant medical conditions, failing to invite or involve the residents or their representatives as required by policy. The DON confirmed that documentation for these meetings was missing or that meetings had not been scheduled or completed.
Two cognitively impaired residents were left unsupervised, resulting in one resident entering another's room and engaging in inappropriate sexual contact. The incident was witnessed by a CNA, who left to find an LPN rather than immediately intervening, leading to a delay in separating the residents. Both residents had significant cognitive deficits, and the facility's policy required prevention of such abuse, but the residents were not adequately protected.
A resident with severe cognitive impairment and multiple medical conditions was found with unexplained facial injuries, including scratches and discoloration. The injuries were not present the previous day and could not be explained by the resident or staff. Despite facility policy requiring immediate reporting of injuries of unknown origin to authorities, the incident was not reported as required.
Failure to Maintain Cleanliness of Personal Fans in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for two residents by not ensuring the cleanliness of personal fans in their rooms. Facility policy requires housekeeping staff to maintain the cleanliness of each resident's room daily, including cleaning low-touch surfaces on a scheduled basis. Observations revealed that both residents had personal fans on their bedside tables, positioned to blow air toward their faces. The fans had visible gray dust on the blades and thick debris resembling clumped gray fibers on the protective grilles. Both residents were present in their rooms at the time of observation and confirmed the use of the fans. One resident had diagnoses including colon cancer, heart disease, chronic pain, and major depressive disorder, and was assessed as cognitively intact. The other resident had heart valve disease, heart failure, and chronic respiratory failure with hypoxia, and was assessed as having mild cognitive impairment. The Environmental Services Director confirmed that the fans in both rooms were not clean and acknowledged that rooms and equipment should be dusted and cleaned daily, as per facility policy.
Misappropriation of Narcotic Medication by LPN
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of narcotic medications. A licensed practical nurse (LPN) signed out additional doses of Hydrocodone-Acetaminophen for a resident who was prescribed this medication for chronic pain related to osteoarthritis, but there was no physician order for extra or PRN doses. The medication administration record showed the resident only received the scheduled doses, and there was no documentation that the resident received the additional doses signed out by the LPN. The resident's pain scores on the relevant days indicated minimal pain, and the resident later reported no concerns regarding pain medication administration. The misappropriation was discovered when a registered nurse (RN) noticed discrepancies during a narcotic count and reported the issue to the Assistant Director of Nursing (ADON). An audit by the Pharmacy Nurse Consultant confirmed that extra doses had been signed out for the resident, but not administered. The LPN admitted to signing out and taking the extra medication for personal use. The facility's policy requires oversight to prevent misappropriation of resident property, but the LPN was able to divert narcotic medication by signing out extra doses without detection until the audit and count revealed the discrepancy. Interviews with staff and review of documentation confirmed that the resident did not miss any scheduled doses and did not experience harm as a result of the incident. The misappropriation was limited to the LPN signing out and diverting narcotic medication intended for the resident, in violation of facility policy and resident rights. The incident was reported to appropriate authorities, and the facility's failure to prevent this misappropriation constituted a deficiency under F-602.
Medication Error Resulting in Severe Hypotension and Hospitalization
Penalty
Summary
A significant medication error occurred when a registered nurse (RN) administered medications intended for another resident to a cognitively intact resident who required supervision with activities of daily living. The nurse failed to verify the resident's identity and did not check the medication labels for the correct resident, medication, dosage, time, or route of administration prior to giving the medications. This action was in direct violation of the facility's medication administration policy, which requires verification of the 'five rights' before administering any medication. The error was not identified at the time of administration or during subsequent documentation. Approximately two hours after receiving the incorrect medications, the resident developed symptoms including dizziness and lightheadedness, and questioned the nurse about the medications received. Upon review, it was discovered that the resident had been given a combination of medications including antihypertensives and other drugs, which were not prescribed for him. This led to severe hypotension, with blood pressure readings dropping to critically low levels, necessitating emergency medical intervention and hospitalization. The resident's medical history included hemiplegia, atrial fibrillation, hypertensive chronic kidney disease, hypertension, and anemia. The administration of the wrong medications resulted in harm, specifically severe hypotension and hospitalization. The incident was attributed to the nurse being distracted while preparing medications and not following established clinical standards and facility policy for safe medication administration.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for six residents as required by both facility policy and state regulations. Policy review indicated that any incident of unknown origin or suspicious in nature must be reported to the State of Tennessee within two hours, regardless of the resident's medical conditions. Despite this, multiple incidents involving injuries such as skin tears, hematomas, abrasions, and discolorations were documented in resident records and incident reports without subsequent notification to the state agency. The residents involved were all cognitively impaired to varying degrees, with several being severely impaired and unable to communicate the cause of their injuries. For example, one resident was found with a skin tear to the right forearm of unknown cause, another with a 6-inch hematoma to the left forearm, and others with abrasions or discolorations, all of which were unexplained. In each case, the facility completed internal documentation and notified responsible parties or physicians, but did not report the incidents to the state as required for injuries of unknown origin. During an interview, the Administrator acknowledged that incidents of unknown origin should be reported but admitted that these specific cases were not reported. The Administrator also indicated a reliance on staff trust and did not provide evidence of investigations that would rule out abuse or neglect. This lack of reporting and investigation for injuries of unknown origin constituted a failure to comply with both facility policy and state requirements.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to conduct complete and thorough investigations for injuries of unknown origin in six out of eight sampled residents reviewed for abuse. According to the facility's abuse policy, incident reports are required for all resident incidents, including falls, bruising, and skin tears, and each incident must be sufficiently investigated to determine the cause and include comments to prevent further injury. However, for each of the six residents cited, the facility was unable to provide documentation of any investigation accompanying the incident reports for injuries such as skin tears, hematomas, abrasions, and discoloration of unknown origin. The residents involved had significant cognitive impairments, as indicated by low BIMS scores, and multiple comorbidities such as Alzheimer's Disease, cerebral infarction, dementia, and chronic kidney disease. The incidents included findings such as a superficial skin tear, a large hematoma, a 1 cm skin tear, an abrasion, and purple discoloration, all with unknown causes. In each case, the incident was documented, but no investigation records were available to determine the cause or rule out abuse, as required by facility policy. Interviews with the DON and Administrator revealed that investigations into these incidents were either not conducted or not documented. The DON stated that discussions with staff about skin incidents are usually documented and attached to the incident report, but was unable to provide such documentation for the cited cases. The Administrator acknowledged that investigations were not routinely performed for incidents of unknown origin, often attributing injuries to resident behaviors or cognitive status without further inquiry or documentation. This lack of investigation and documentation led to the deficiency cited by surveyors.
Failure to Document Daily Food Storage Temperatures
Penalty
Summary
The facility failed to ensure that food was stored, handled, prepared, and served under sanitary conditions as required by both facility policy and professional standards. Specifically, the facility did not record the temperatures of the refrigerator, freezer, and cooler on multiple days throughout September 2025, as evidenced by a review of the Record of Refrigeration Temperatures. The facility's own policy mandates that the temperature of each freezer and refrigerator be checked and recorded daily to prevent contamination and bacterial growth. However, documentation was missing for several dates for each piece of equipment. During an interview, the Dietary Manager confirmed that temperatures for the refrigerator, freezer, and cooler should be checked and recorded daily. Despite this requirement, the lack of documentation indicates that this process was not consistently followed. As a result, 38 residents received food trays from the kitchen during the period when temperature monitoring was not properly documented.
Failure to Implement and Monitor Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and implement an effective infection prevention and control program as required by policy and regulation. The Infection Preventionist (IP)/Director of Nursing (DON) did not track infections by specific organisms, nor did they monitor for outbreaks or cross contamination among residents. Documentation reviewed, including the Nosocomial Infection Summary and Line Listing of Patient Infections, lacked information on the specific organisms involved in infections, and the IP/DON confirmed that such tracking was not performed. Additionally, there was no evidence that the facility monitored for cross contamination or investigated potential outbreaks, even when multiple urinary tract infections (UTIs) occurred on the same hallway within a month. For one resident, who had diagnoses including deep tissue damage, osteomyelitis, and malignant neoplasm of the prostate, the facility failed to implement Enhanced Barrier Precautions (EBP) as ordered by the physician. Observations revealed that EBP signage was not posted on the resident's door, and staff did not consistently use the required personal protective equipment (PPE) during wound care. Specifically, staff entered the resident's room, donned gloves but not gowns, and performed wound care without following the EBP protocol, despite being aware that the resident was under EBP. Interviews with staff, including an LPN and the Assistant Director of Nursing (ADON), confirmed that EBP signage should have been present and that both gown and gloves were required for wound care. The lack of signage and failure to use appropriate PPE during high-contact care activities demonstrated a breakdown in the facility's infection control practices, as outlined in their own policies and job descriptions.
Failure to Hold and Document Required Care Plan Meetings with Resident Participation
Penalty
Summary
The facility failed to ensure that care plan conference meetings were held on admission and quarterly for two residents, as required by both facility policy and federal and state standards. Facility policy mandates that a care plan meeting be held within seven days following a new comprehensive assessment and that these meetings be reviewed and updated at least quarterly, with the resident and/or their representative invited and encouraged to participate. Documentation of the meeting, including participant names and roles, is required, and if the resident or representative chooses not to participate, this must be documented. However, for one resident with diagnoses including traumatic subarachnoid hemorrhage, convulsions, cerebral infarction, and pain, there was no documentation that care plan meetings were held or that the resident or representative was invited following multiple MDS assessments, despite varying levels of cognitive function as indicated by BIMS scores. The care plan for this resident was last reviewed and revised on 9/15/2025, but required documentation for prior meetings was missing. Similarly, another resident with fractures of both femurs and seizures was admitted and had an admission MDS assessment indicating moderate cognitive impairment. The facility was unable to provide documentation that a care plan meeting was held or that the resident or representative was invited following the admission assessment. The care plan for this resident was also last reviewed and revised on 9/15/2025. During an interview, the Interim DON confirmed that she could not provide documentation for the required care plan meetings for either resident and acknowledged that a care plan meeting had not been scheduled or completed for the second resident.
Failure to Prevent Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect two residents from sexual abuse, as required by its own policy and federal regulations. The incident involved a resident with severe cognitive impairment, including traumatic brain injury and paranoid schizophrenia, who entered the room of another resident with moderate cognitive impairment and dementia. The first resident was found in bed with the second resident, both unclothed from the waist down, engaging in inappropriate sexual contact. The event was witnessed by a CNA, who left the room to find a nurse, and the nurse subsequently intervened to separate the residents. Medical record reviews indicated that both residents had significant cognitive deficits, with one unable to complete a mental status interview and the other displaying moderate impairment and short-term memory loss. The facility's policy outlined the need to prevent all forms of abuse, including sexual abuse, and to identify residents at increased risk, such as those with confusion or behavioral disturbances. Despite these policies, the residents were left unsupervised, and the incident was not immediately interrupted when first discovered by staff. Camera footage confirmed that the residents remained together and unattended for a period after the inappropriate interaction was witnessed. Interviews with staff revealed that there was no prior history of sexual aggression for either resident, and that staff were aware of the cognitive and behavioral challenges faced by both individuals. The CNA who discovered the incident did not immediately separate the residents but instead left to find a nurse, resulting in a delay. The nurse who responded found both residents unclothed and intervened to remove the first resident from the room. The incident was reported to law enforcement and Adult Protective Services, and both residents were subsequently monitored in separate locations.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for one resident as required by its own policy and federal and state law. The policy mandates that all injuries of unknown origin, defined as injuries where the source is not observed or cannot be explained by the resident and are suspicious due to their extent or location, must be immediately reported to the Facility Administrator and appropriate agencies. In this case, a resident with severe cognitive impairment and multiple medical diagnoses, including subdural hematoma and Down's Syndrome, was found with scratch marks on the forehead and purplish discoloration and swelling around the left eye. The resident was unable to explain the cause of the injuries, and staff interviews confirmed that the injuries were not present the previous day. Despite the facility's policy and the nature of the injuries, there was no evidence that the injury of unknown origin was reported to state and local agencies as required. The former DON acknowledged that the injury was initially considered of unknown origin until the investigation concluded. Staff documentation and interviews confirmed the injuries were first observed during morning care, and the resident was non-verbal and unable to communicate about the incident. The Administrator confirmed that such injuries should be reported, but the required reporting did not occur.
Some of the Latest Corrective Actions taken by Facilities in Tennessee
Explore Popular Searches
