Tennessee State Veterans Home- Cleveland

In the surveyor’s words

From the most serious findings on record at Tennessee State Veterans Home- Cleveland, in the surveyor’s own words.

• Actual harm, isolatedF600Jan 22, 2026

  Based on facility policy review, medical record review, facility documentation review, geriatric psychiatric (geri-psych) hospital documentation review, observation, and interviews, the facility failed to protect 1 resident (Resident #103) of 6 residents reviewed for abuse from sexual abuse which resulted in actual Psychosocial Harm to Resident #103. The findings include: 1. Review of the facility's policy titled, Abuse & Neglect of Residents and Misappropriation of Residents' Property, dated 1/22/2025, revealed .Every resident has the right to be free from .sexual .abuse .Residents must not be subjected to abuse by anyone, including, but not limited to .other residents .Sexual Abuse .includes but is not limited to sexual harassment, sexual coercion, or sexual assault .understanding… […]

• No harm, potential for more than minimal, isolatedF557Jan 22, 2026

  Based on facility policy review, medical record review, facility documentation review, and interview, the facility failed to ensure residents right to privacy for 1 resident (Resident #49) of 32 residents reviewed for resident rights. The findings include: Review of the facility policy titled, Dignity and Quality of Life Policy, dated 1/7/2013, revealed .Staff will respect residents private space by .not moving or inspecting residents personal property without permission . Review of the facility's admission packet dated 10/2022, revealed .You have the right to be treated with respect and dignity .The right to retain and use personal possessions .You have the right to personal privacy . […]

• No harm, potential for more than minimal, isolatedF582Jan 22, 2026

  Based on medical record review, facility documentation review, and interview, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for 1 resident (Residents #116) of 3 residents reviewed for beneficiary notices. The findings include: Review of the medical record revealed Resident #116 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Muscle Weakness, Difficulty in Walking, and Fracture of Shaft of Humerus with Routine Healing. Review of the Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility staff indicated Resident #116 was discharged from a Medicare covered Part A stay with benefit days remaining on 11/8/2025 and remained in the facility. […]

• No harm, potential for more than minimal, isolatedF641Jan 22, 2026

  Based on facility policy review, Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, medical record review, and interviews, the facility failed to ensure MDS assessments were accurate for 5 residents (Residents #107, #38, #96, #43, #54) of 22 residents reviewed for MDS assessments. The findings include: Review of the facility's policy titled, Minimum Data Set (MDS) Policy, dated [DATE], revealed .will utilize the Minimum Data Set (MDS) .for the Resident Assessment Tool .will have MDS assessments completed in accordance with OBRA [Omnibus Budget Reconciliation Act] and Medicare Guidelines .Completion of the MDS 3.0 assessments is a multi-disciplinary product and is overseen by the MDS Coordinator and assistants . […]

• No harm, potential for more than minimal, isolatedF880Jan 22, 2026

  Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure Transmission Based Precautions (TBP) were maintained for 1 resident (Resident #73) of 1 resident observed in TBP and failed to ensure appropriate Personal Protective Equipment [PPE] was donned (applied) for 1 resident (Resident #10) in Enhanced Barrier Precautions (EBP) of 4 residents observed in EBP. The findings include: Review of the facility's policy titled, Infection Control Manual, dated 4/25/2024, revealed .Transmission-Based Precautions [TBP] .should be implemented for Residents known or suspected to be infected with an infectious agent requiring additional control measures .Three types of TBP .contact precautions .PPE SUPPLY .Provide a table, cart, dispensing units… […]