Based on facility policy, record review and interview, the facility failed to ensure a Certified Nurse Aide (CNA)followed the care plan for one (Resident #4) of eight sampled residents during a transfer with a mechanical lift. CNA #1 transferred Resident #4 using a mechanical lift without requesting the assistance of another staff member and without connecting the sling securely to the lift as instructed in the resident's care plan and Minimum Data Set (MDS) (an assessment tool for long term care). Review of the facility policy titled, Lift & Transfer Program revealed, Two trained persons are required to be present when using the lift. Resident #4 fell from the lift during a transfer and sustained a right leg fractured fibula and fractured cervical (neck) vertebrae at C1. …
F659 citations in Tennessee
Resident Assessment and Care Planning Deficiencies
Provide care by qualified persons according to each resident's written plan of care.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
No F659 citations were recorded in Tennessee for 2025. That means none appear in the CMS file for that year — not that the requirement does not apply.
In the surveyor’s words
What Tennessee surveyors wrote
F659 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 policy review, medical record review, observation, and interview the facility failed to follow standards of practice for administering crushed medications through a percutaneous enteral feeding tube when 1 of 3 (Licensed Practical Nurse (LPN #1) nurses mixed crushed medications together when administering the medications through an enteral feeding tube to 1 of 1 (Resident #65) residents with an enteral feeding tube. The findings include: The facility's undated .Enteral Tube Feeding . …
What else Tennessee surveyors cite →
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