Based on review of facility policy, review of a hospice service agreement, medical record review, review of a facility investigation, and interviews, the facility failed to ensure an effective communication process and procedure was in place with a hospice provider to ensure a Do Not Resuscitate (DNR) status was honored for 1 resident (Resident #1) of 6 residents reviewed for hospice services. The facility's failure to ensure effective communication was in place resulted in Resident #1 receiving Cardiopulmonary Resuscitation (CPR) against the resident's and the resident's representative wishes and placed the resident in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury,… …
F849 citations in Tennessee
Administration Deficiencies
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Tennessee cites F849 more often than its own record predicts
1.27 times the share F849 takes of citations nationally.
Of every deficiency written in Tennessee in 2025, this is the portion that was F849.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Tennessee surveyors wrote
F849 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, medical record review, and interviews, the facility failed to ensure a current coordinated plan of care with the hospice provider was available in the medical record for 1 resident (Resident #52) of 3 residents reviewed for hospice. The findings include:Review of the facility's undated policy titled, Hospice Care Guidelines, revealed .The facility staff will work with hospice representative and will .Collaborate with hospice representatives and coordinating LTC [Long Term Care] facility staff participation in the hospice care planning process for those residents receiving these services .Obtain the following information from the hospice .The most recent hospice plan of care specific to each resident .Review of Nursing Facility Services Agreement, between… …
The short window
Recent years
| Year | Share of Tennessee citations | vs expected |
|---|---|---|
| 2023 | 0.49% | 1.57× |
| 2024 | 0.24% | 0.80× |
| 2025 | 0.35% | 1.27× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Tennessee surveyors cite →
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