Based on facility policy review, medical record review, and interview, the facility failed to provide written notification of a discharge to a resident's representative for 1 resident (#11) of 13 residents reviewed for transfer/discharge requirements. The facility's failure resulted in Resident #11, a cognitively impaired resident with multiple medical and psychological conditions and limited family/social support, being discharged to an unsupervised home without notice to a care giver and placed Resident #11 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). …
F623 citations in Tennessee
Notice before transfer or discharge · Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Tennessee cites F623 less often than its own record predicts
0.28 times the national share — cited less often here than elsewhere.
Of every deficiency written in Tennessee in 2025, this is the portion that was F623.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Tennessee surveyors wrote
F623 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, record review, and interview, the facility failed to ensure three out of three residents (Resident (R) 49, R259, and R76) and/or their representatives reviewed for hospitalization were provided with written transfer notices upon emergent transfer to the hospital and ensure notification was provided to the ombudsman. Findings include: 1.Review of the facility policy titled, Resident Discharge Policy, approved on 11/11/13, revealed Policy .will give timely and proper notice for any intent to transfer or discharge a resident when permitted by Federal or State rules .Procedure .(i) Notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the transfer or discharge in writing and… …
Based on record review, interview, and facility policy review, the facility failed to notify in writing the resident and the resident's representative regarding the resident's emergent transfer to the hospital for nine residents (Resident (R) 10, R17, R37, R47, R7, R62, R275, R72, and R59) of nine residents reviewed for hospitalization in a total sample of 31 residents. This failure had the possibility to affect every resident (current census of 82 Residents) that was transferred to the hospital during their stay at the facility by not being aware of their appeal rights. Findings include: Review of the facility's policy titled, Transfer/discharge date d 03/2024 indicated, 2.1. A. A patient may be transferred or discharged to another health care institution . …
The short window
Recent years
| Year | Share of Tennessee citations | vs expected |
|---|---|---|
| 2023 | 0.49% | 0.54× |
| 2024 | 0.37% | 0.36× |
| 2025 | 0.12% | 0.28× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Tennessee surveyors cite →
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