Based on the 2026 American Heart Association/American Stoke Association (AHA/ASA) Guidelines, facility policy review, hospital record review, medical record review, facility documentation review, emergency medical transportation review, and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 6 (Resident #1) sampled residents reviewed for physical injuries, timely assessments, and emergency transfer for a change in condition. Resident #1, a vulnerable Resident who was cognitively intact, with a full code status, was found with an acute change in condition and altered mental status on the morning of 7/10/202 at approximately 10:56 AM. …
F684 citations in Tennessee
Quality of care · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Tennessee cites F684 less often than its own record predicts
0.88 times the national share — cited less often here than elsewhere.
Of every deficiency written in Tennessee in 2025, this is the portion that was F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Tennessee surveyors wrote
F684 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, hospital record review and interview, the facility failed to ensure residents received the necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection for residents determined to be at risk of skin breakdown for 1 of 3 (Resident #85) sampled residents reviewed for wounds. Resident #85 was admitted to the facility on [DATE], and readmitted on [DATE], with a right elbow surgical site wound and the use of a single use negative pressure wound therapy system dressing (Named system that uses vacuum suction to promote healing, generally kept in place for 7 to 14 days) covered by a soft splint. …
Based on medical record review, observation, and interview, the facility failed to assess and monitor the resident's skin under an immobilizer for 1 of 1 (Resident #100) residents reviewed for immobilizers.The findings include: Review of the medical record review revealed Resident #100 was admitted to the facility on [DATE], with diagnoses including Osteoarthritis Right Shoulder, Diabetes, Epilepsy, and Depression. Review of the Care plan dated 6/17/2026, revealed .Potential Skin Impairment r/t [related to] mobility. sling right shoulder. Review of the Physician's Order dated 6/24/2026, revealed .Monitor skin integrity and capillary refill. Ensure R [right] shoulder sling intact one time a day . …
The short window
Recent years
| Year | Share of Tennessee citations | vs expected |
|---|---|---|
| 2023 | 4.13% | 1.14× |
| 2024 | 3.53% | 0.89× |
| 2025 | 3.80% | 0.88× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Tennessee surveyors cite →
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