Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain a safe, clean, homelike environment for 4 resident rooms (room [ROOM NUMBER], # 216, #220, and #219) on 1 of 3 hallways observed. The findings include: Review of the facility's policy titled, Resident Belongings and Home like Environment, revised 4/1/2026, revealed .facility will provide .homelike environment .Refers to any environment in the facility that is frequented by residents .including .the residents' rooms . 1. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Anxiety, and Depression. …
F921 citations in Tennessee
Safe, clean, comfortable environment · Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Tennessee cites F921 more often than its own record predicts
1.36 times the share F921 takes of citations nationally.
Of every deficiency written in Tennessee in 2025, this is the portion that was F921.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Tennessee surveyors wrote
F921 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, observation and interview the facility failed to provide a safe, sanitary, and comfortable environment for all residents on 4 of 4 halls observed in the facility. The findings include: Review of the facility policy, Preventive Maintenance- Exhaust Fan Inspection, revealed .all exhaust fans will be inspected on a monthly basis or more often if needed . Observations made 10/29/18 through 10/31/18 during the survey revealed multiple rooms on 4 of 4 hallways with a large amount of dust and debris in the residents' bathroom exhaust fan vents. Interview with the Maintenance Director on 10/31/18 at 12:50 PM, in the hallway, confirmed the exhaust fan vents were in need of cleaning and were not on a set cleaning schedule.
The short window
Recent years
| Year | Share of Tennessee citations | vs expected |
|---|---|---|
| 2023 | 0.49% | 0.58× |
| 2024 | 0.49% | 0.61× |
| 2025 | 1.15% | 1.36× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Tennessee surveyors cite →
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