2 Reports
Inspection Report — Aug 26, 2026
Follow-Up
Date: Aug 26, 2026
Visit Reason
Order of Compliance issued after the Petitioner submitted a petition and evidence showing the conditions of the October 22, 2025 Contingent Change of Ownership/Consent Order were met.
Findings
The Commission ordered that the petitioner is relieved of further responsibilities under the October 22, 2025 Consent Order; the probation of the ACLF license is lifted and the license is restored to active, unencumbered status. The earlier Order had placed the license on probation not to exceed six months and assessed civil monetary penalties totaling $7,750.00 and required monthly QAPI reports.
Report Facts
Sanction lifted: 1
Inspection Report — Oct 22, 2025
Enforcement
Date: Oct 22, 2025
Visit Reason
Contingent Change of Ownership Order granting a change of ownership application subject to contingencies and imposing sanctions following a survey completed on September 6, 2024 (Survey 1) and a revisit survey completed on October 10, 2024 (Survey 2).
Findings
The Commission granted the Change of Ownership Application subject to contingencies and assessed multiple civil monetary penalties for violations cited in Survey 1 and Survey 2, totaling $7,750, and placed the facility on probation for up to six (6) months. The Order requires payment of outstanding civil monetary penalties within thirty (30) days of ratification and other reporting and compliance conditions.
Citations (5)
Tenn. Comp. R. & Reg. 0720-26-.07(7)(a)(2): Failure to ensure resident safety; Resident #1 sustained seventeen (17) falls from January through August 2024 and the facility failed to implement appropriate interventions and staff education related to fall/incident documentation. Three (3) residents were also using medically necessary oxygen in their rooms without required door signage.
Tenn. Comp. R. & Reg. 0720-26-.07(7)(c)(4)(i): Failure to provide safe meals and maintain food service temperature controls; the facility failed to document temperatures for the high temperature dishwasher, refrigerator, and freezer between May 17 and August 20, 2024, and some units were not operating at acceptable temperatures.
Tenn. Comp. R. & Reg. 0720-26-.07(7)(c)(4)(iii): Failure to maintain and properly store a forty-eight (48) hour food supply; several food items were stored opened or uncovered without appropriate labeling and/or dates.
Tenn. Comp. R. & Reg. 0720-26-.07(7)(c)(5): Failure to maintain a clean and sanitary kitchen; kitchen staff were observed not wearing hairnets and did not have access to hairnets.
Tenn. Comp. R. & Reg. 0720-26-.12(1): Failure to develop and maintain organized resident medical records; Resident #80's medical record lacked updated diagnoses, physician orders, a documented discharge date, and the Service Plan was not signed by the resident, a responsible party, or appropriate facility staff.
Report Facts
Civil monetary penalties assessed: 9
Total civil monetary penalty amount: 7750
Probation length in months: 6
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