CMS · Tennessee Department of Health publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F552Ensure that residents are fully informed and understand their health status, care and treatments.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-18Record 445237-20260212-F552
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-18Record 445237-20260212-F580
F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-18Record 445237-20260212-F604
F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-18Record 445237-20260212-F605
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-18Record 445237-20260212-F695
F850Hire a qualified full-time social worker in a facility with more than 120 beds.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-18Record 445237-20260212-F850
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity KHarm
Care planning
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-12-16Record 445237-20241118-F684
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity LHarm
Staffing
Widespread; immediate jeopardy to resident health or safety.Corrected 2024-12-16Record 445237-20241118-F726
F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Scope/severity LHarm
Records
Widespread; immediate jeopardy to resident health or safety.Corrected 2024-12-16Record 445237-20241118-F835
F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.Scope/severity LHarm
Records
Widespread; immediate jeopardy to resident health or safety.Corrected 2024-12-16Record 445237-20241118-F837
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity LHarm
Records
Widespread; immediate jeopardy to resident health or safety.Corrected 2024-12-16Record 445237-20241118-F867
F880Provide and implement an infection prevention and control program.Scope/severity LHarm
Infection control
Widespread; immediate jeopardy to resident health or safety.Corrected 2024-12-16Record 445237-20241118-F880
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-16Record 445237-20241118-F550
F583Keep residents' personal and medical records private and confidential.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-16Record 445237-20241118-F583
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity FStandard
Dignity & rights
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-12-16Record 445237-20241118-F584
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-16Record 445237-20241118-F655
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-16Record 445237-20241118-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-16Record 445237-20241118-F657
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-08Record 445237-20241118-F692
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-16Record 445237-20241118-F695
F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-16Record 445237-20241118-F700
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-16Record 445237-20241118-F756
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-16Record 445237-20241118-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-12-16Record 445237-20241118-F812
F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-16Record 445237-20241118-F838
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-16Record 445237-20241118-F842
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity LHarm
Abuse & neglect
Widespread; immediate jeopardy to resident health or safety.Corrected 2021-07-19Record 445237-20210713-F600
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity LHarm
Abuse & neglect
Widespread; immediate jeopardy to resident health or safety.Corrected 2021-07-19Record 445237-20210713-F609
F610Respond appropriately to all alleged violations.Scope/severity LHarm
Abuse & neglect
Widespread; immediate jeopardy to resident health or safety.Corrected 2021-07-19Record 445237-20210713-F610
F741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.Scope/severity LHarm
Care planningStaffing
Widespread; immediate jeopardy to resident health or safety.Corrected 2021-07-19Record 445237-20210713-F741
F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Scope/severity LHarm
Care planning
Widespread; immediate jeopardy to resident health or safety.Corrected 2021-07-19Record 445237-20210713-F744
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity LHarm
Records
Widespread; immediate jeopardy to resident health or safety.Corrected 2021-07-19Record 445237-20210713-F867