Based on medical record review, review of facility investigations, and interviews, the facility failed to update the baseline care plan with interventions to address a resident's safety needs after an elopement from the facility for 1 resident (Resident #1) of 5 residents reviewed. The facility's failure resulted in a second elopement from the facility and placed the resident in Immediate Jeopardy (IJ) (a situation in which a provider's non-compliance 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 5/12/2022 at 10:00 AM in the Nursing Team Leader office. Immediate Jeopardy was removed onsite and was effective 4/19/2022-5/12/2022. …
F655 citations in Tennessee
Baseline care plan · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Tennessee cites F655 less often than its own record predicts
0.35 times the national share — cited less often here than elsewhere.
Of every deficiency written in Tennessee in 2025, this is the portion that was F655.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Tennessee surveyors wrote
F655 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 fall investigation review, and interview, the facility failed to develop a baseline care plan for fall risk for a resident at high risk for falls resulting in a fall with a laceration which required staples to the back of the head (harm) for 1 resident (Resident #7) of 7 residents reviewed for falls. The findings include: Review of the facility's policy, Falls dated 11/6/2019, revealed, .All residents will have a comprehensive fall risk assessment on admission/readmission .Appropriate care plan interventions will be implemented and evaluated as indicated by assessment .Care Plan will be implemented based on fall risk evaluation score with individual goal and interventions specific to each patient . …
Based on policy review, medical record review, and interview the facility failed to complete a baseline care plan within 48 hours for 10 of 24 (Resident #5, Resident #10, Resident #12, Resident #25, Resident #26, Resident #28, Resident #34, Resident #115, Resident #116, and Resident #166) sampled residents reviewed for baseline care plans. The findings include: 1. Review of the facility policy titled, Care Plans-Baseline, revised 3/2022, revealed .A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission . 2. …
The short window
Recent years
| Year | Share of Tennessee citations | vs expected |
|---|---|---|
| 2023 | 1.16% | 1.45× |
| 2024 | 0.37% | 0.53× |
| 2025 | 0.23% | 0.35× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Tennessee surveyors cite →
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