F835 in Tennessee. Pick another state for the same tag.
Against expectation — 2025
Tennessee cites F835 more often than its own record predicts
Versus expected share1.17×
1.17 times the share F835 takes of citations nationally.
Share of Tennessee citations0.35%
Of every deficiency written in Tennessee in 2025, this is the portion that was F835.
Tennessee0.35%
National0.29%
Share of all citations that were F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Tennessee surveyors wrote
F835 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.
L · Immediate jeopardy, widespreadNovember 18, 2024
Based on facility policy review, Centers for Disease Control and Prevention (CDC) recommendations and guidance review, job description review, facility assessment review, and interviews, the facility's Administration failed to ensure current CDC guidelines were utilized to prevent and control the spread of COVID-19 to the residents and employees. The facility's Administration failed to ensure the staff were competent and knowledgeable on Enhanced Barrier Precautions (EBP) and COVID-19 isolation practices which included use of appropriate Personal Protective Equipment (PPE) for potentially contagious residents. The facility's Administration failed to accurately identify residents with an active diagnosis of COVID-19. …
Based on job description review and interview, Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable wellbeing of the residents. Administration failed to provide oversight to ensure nursing staff provided an environment that is free from accident hazards over which the facility has control, implement care plan interventions for known unsafe behaviors, and provide supervision for 1 of 3 (Resident #1) sampled residents reviewed for falls. On 12/27/2023 Resident #1 had an unwitnessed fall from an elevated bed and sustained bilateral lower extremity compound fractures of the tibia and fibula and a comminuted fracture of the left patella. …
F · No harm, potential for more than minimal, widespreadMarch 28, 2026
Based on facility policy review, job description review, facility documentation review, Quality Assurance and Performance Improvement (QAPI) Plan review, and interview, the facility's Administration failed to provide effective leadership and oversight after 1 resident (Resident #49) was not identified by facility staff as having exhibited sexually abusive behaviors or activities. This failure of staff who were trained in Dementia care and Abuse allowed the sexual behaviors to persist which allowed continued non-consensual sexually inappropriate behaviors and abuse. …
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