Based on review of facility policy, review of facility investigation, medical record review, and interview, the facility failed to correctly document residents' medical problems including assessments of residents with pain for 2 residents (#24, #61) of 48 residents reviewed. The facility's failure to provide accurate assessments placed Resident #24 and Resident #61 in Immediate Jeopardy (a situation where the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death to a resident). The Administrator was notified of the Immediate Jeopardy on 2/28/18 at 4:05 PM in the Administrator's office. The Immediate Jeopardy was effective from 11/21/17 through 2/23/18. …
F641 citations in Tennessee
Accuracy of assessments · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Tennessee cites F641 more often than its own record predicts
1.94 times the share F641 takes of citations nationally.
Of every deficiency written in Tennessee in 2025, this is the portion that was F641.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Tennessee surveyors wrote
F641 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 medical record review, observation, and interview, the facility failed to provide skin assessments for Resident (#68). Resulting in development of skin pressure ulceration to the right axilla and arm resulting in (HARM). Medical record review revealed Resident #68 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 6/12/17, revealed the problem of .altered integument (skin) .fragile and poorly perfused skin . with approaches including .weekly skin assessment to be performed/documented by nursing . Further review of the Care Plan revealed Resident #68 was readmitted on [DATE] with intact, but fragile and poorly perfused skin. …
Based on Centers for Medicare and (&) Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 review, medical record review, observations, and interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments for 2 residents (Resident #14 and Resident #5) of 16 residents reviewed for MDS assessment accuracy. The findings include: Review of Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated 10/2025, revealed .primary purpose as an assessment instrument is to identify resident care problems .the assessment [MDS] accurately reflects the resident's status .A1500 .Preadmission Screening and Resident Review (PASRR) .Code .yes… …
The short window
Recent years
| Year | Share of Tennessee citations | vs expected |
|---|---|---|
| 2023 | 1.98% | 1.16× |
| 2024 | 3.65% | 2.17× |
| 2025 | 3.57% | 1.94× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Tennessee surveyors cite →
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