Based on policy review, National Weather Service website review, medical record review, facility video footage review, fall investigation documentation review, Facility Reportable Incident investigation review, hospital record review, observation and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent an incident of elopement for 1 of 3 (Resident #62) sampled residents reviewed for wandering/elopement risk. The facility's failure resulted in Immediate Jeopardy on Sunday 12/22/2024 at 7:04 PM, when Resident #62, a vulnerable and cognitively impaired resident with wandering behaviors, eloped from the facility in temperatures of 30 degrees Fahrenheit, without a coat or layered clothing, fell and was subsequently transferred back into his… …
F689 citations in Tennessee
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Tennessee cites F689 more often than its own record predicts
1.25 times the share F689 takes of citations nationally.
Of every deficiency written in Tennessee in 2025, this is the portion that was F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Tennessee surveyors wrote
F689 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, the facility's Appropriate Bed Height education document, medical record review, and interview, the facility failed to ensure residents remained free from accident hazards for 1 of 3 (Resident #46) sampled residents reviewed for accident hazards. On 9/5/2025, Certified Nursing Assistant (CNA) E left Resident #46's bed at an unsafe height and the resident inappropriately positioned in the bed after bathing the resident when she exited the resident's room to retrieve supplies. Resident #46 fell from the bed, fractured and dislocated her right humerus (upper arm), requiring transfer to the emergency room (ER) and treatment for a fracture (FX). The facility's failure to ensure an environment free from accident hazards resulted in an actual Harm to Resident #46. …
Based on facility policy review, medical record review, facility investigation review, and interview, the facility staff failed to timely notify the responsible nursing staff of a fall for 1 resident, (Resident #9) of 3 residents reviewed for falls. The facility was cited at F 689 at a Scope and Severity of D as Past Non-Compliance. No additional corrective actions are required. The facility is not required to submit a Plan of Correction. The findings include: Review of the facility policy titled, Fall Prevention-Program Policy, dated 7/2026, revealed . …
The short window
Recent years
| Year | Share of Tennessee citations | vs expected |
|---|---|---|
| 2023 | 4.95% | 1.00× |
| 2024 | 5.85% | 1.09× |
| 2025 | 6.90% | 1.25× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Tennessee surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction