F656 in Tennessee. Pick another state for the same tag.
Against expectation — 2025
Tennessee cites F656 less often than its own record predicts
Versus expected share0.97×
0.97 times the national share — cited less often here than elsewhere.
Share of Tennessee citations3.34%
Of every deficiency written in Tennessee in 2025, this is the portion that was F656.
Tennessee3.34%
National3.44%
Share of all citations that were F656.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Tennessee surveyors wrote
F656 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.
J · Immediate jeopardy, isolatedMay 24, 2024
Based on review of facility policy, medical record review, and interviews, the facility failed to develop a comprehensive care plan and implement appropriate interventions for 1 of 4 (Resident #2) sampled residents reviewed for care plans. On 4/23/2024, Resident #2's family member was observed being verbally and physically abusive toward Resident #2 and the facility failed to develop interventions to ensure Resident #2 was safe and monitored for his psychosocial wellbeing, latent injuries, and ensure all staff members were aware Family member #2 was not allowed in the facility following an abuse incident by a Family member. …
Based on facility policy review, medical record review, hospital record review, and interview the facility failed to implement care plan interventions related to safe transfers with a mechanical lift for 1 resident (Resident #5) of 10 resident care plans reviewed which resulted in actual Harm for Resident #5.
The findings include:
Review of the facility policy titled, Comprehensive Care Plans and Revisions, dated 9/11/2024, revealed .The facility will ensure .each resident's person-centered [care plan] .is reviewed and revised .that includes but not limited to .appropriate staff .by resident's needs . …
D · No harm, potential for more than minimal, isolatedAugust 7, 2026
Based on facility policy review, medical record review, observation, and interview, the facility failed to implement a care plan intervention for a specialty mattress for 1 resident (Resident #52) of 21 residents reviewed for care plans. The findings include: Review of the facility's undated policy titled, Fall Prevention & [and] Management Program guidelines, revealed .Each resident .will receive care .to minimize the likelihood of falls .Interventions will be monitored for effectiveness . Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's Disease, Diabetes Mellitus, Unsteadiness on Feet, and Repeated Falls. …
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