Based on policy review, incontinent brief manufacturer directions, medical record review, hospital record review, facility investigation review, observation, and interview, the facility failed to protect the Residents' right to be free from neglect when they failed to provide necessary care and services to meet the needs of the Resident for 1 of 6 (Resident #1) sampled residents reviewed for a change of condition and altered mental status. Resident #1, a vulnerable Resident who was cognitively intact, with a full code status was found with an acute change in condition on 7/10/2024 at approximately 10:56 AM. The facility failed to notify the physician and the family at that time. …
F600 citations in Tennessee
Abuse and neglect · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Tennessee cites F600 less often than its own record predicts
0.79 times the national share — cited less often here than elsewhere.
Of every deficiency written in Tennessee in 2025, this is the portion that was F600.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Tennessee surveyors wrote
F600 findings written in Tennessee, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on facility policy review, medical record review, facility documentation review, geriatric psychiatric (geri-psych) hospital documentation review, observation, and interviews, the facility failed to protect 1 resident (Resident #103) of 6 residents reviewed for abuse from sexual abuse which resulted in actual Psychosocial Harm to Resident #103. The findings include: 1. Review of the facility's policy titled, Abuse & Neglect of Residents and Misappropriation of Residents' Property, dated 1/22/2025, revealed .Every resident has the right to be free from .sexual .abuse .Residents must not be subjected to abuse by anyone, including, but not limited to .other residents .Sexual Abuse .includes but is not limited to sexual harassment, sexual coercion, or sexual assault .understanding… …
Based on facility policy review, medical record review, facility documentation review and interviews the facility failed to protect 1 resident (Resident #1) from sexual abuse of 5 residents reviewed for abuse.The findings include: Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation, revealed .Sexual Abuse is non-consensual sexual contact of any type with a resident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Aphasia (difficulty communicating), Hemiplegia (paralysis of one side of the body) and Hemiparesis (muscle weakness affecting one side of the body) affecting right dominant side, and Memory Deficit following Cerebral Infarction (stroke). …
The short window
Recent years
| Year | Share of Tennessee citations | vs expected |
|---|---|---|
| 2023 | 3.80% | 2.14× |
| 2024 | 5.85% | 2.48× |
| 2025 | 2.07% | 0.79× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Tennessee surveyors cite →
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