Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ascension Living Alexian Village Tennessee during CMS and state inspections, most recent first.
A nurse administered medications intended for another resident to a cognitively intact individual with multiple chronic conditions, failing to verify identity or medication details as required by policy. The error was not recognized until the resident developed severe hypotension and required hospitalization. The incident was caused by distraction and failure to follow established medication administration protocols.
The facility failed to maintain a homelike environment for two residents. One resident with moderate cognitive impairment was in a room with a damaged baseboard and gouges in the wall, covered with tape. Another resident with severe cognitive impairment was in a room with tears in the paint and drywall. The administrator confirmed the need for repairs.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with indwelling urinary devices. Despite having suprapubic or indwelling catheters, the care plans did not include EBP, and there was no signage or PPE available. Interviews with staff, including an LPN and CNAs, revealed a lack of awareness and implementation of EBP requirements, as they only wore gloves during catheter care.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling devices, as required by their infection control policy. Observations and interviews revealed that staff were not using gowns and gloves during high-contact activities for residents with catheters. Residents and staff were unaware of the need for EBP, and there was no signage or PPE available, indicating a systemic failure to adhere to infection control protocols.
A facility failed to accurately complete an MDS assessment for a resident with multiple diagnoses, including COPD and Vascular Dementia. Despite a fall incident on December 27, 2023, which required emergency evaluation, the quarterly MDS assessment dated January 25, 2024, did not document any falls. The Interim MDS Coordinator confirmed the inaccuracy during an interview.
A facility failed to remove discontinued narcotics from inventory, leading to discrepancies in medication documentation for a resident with severe cognitive impairment. Despite the discontinuation of Percocet, it was documented as withdrawn by an RN without administration records. The resident did not report pain or request medication, and the RN did not respond to investigation attempts, suggesting potential diversion.
A resident with a history of falls experienced an unwitnessed fall that was not documented in their medical record, contrary to facility policy. The fall was discovered after an Environmental Services employee reported a new skin injury, leading to an investigation. The responsible agency nurse failed to document the incident, resulting in their termination.
Medication Error Resulting in Severe Hypotension and Hospitalization
Penalty
Summary
A significant medication error occurred when a registered nurse (RN) administered medications intended for another resident to a cognitively intact resident who required supervision with activities of daily living. The nurse failed to verify the resident's identity and did not check the medication labels for the correct resident, medication, dosage, time, or route of administration prior to giving the medications. This action was in direct violation of the facility's medication administration policy, which requires verification of the 'five rights' before administering any medication. The error was not identified at the time of administration or during subsequent documentation. Approximately two hours after receiving the incorrect medications, the resident developed symptoms including dizziness and lightheadedness, and questioned the nurse about the medications received. Upon review, it was discovered that the resident had been given a combination of medications including antihypertensives and other drugs, which were not prescribed for him. This led to severe hypotension, with blood pressure readings dropping to critically low levels, necessitating emergency medical intervention and hospitalization. The resident's medical history included hemiplegia, atrial fibrillation, hypertensive chronic kidney disease, hypertension, and anemia. The administration of the wrong medications resulted in harm, specifically severe hypotension and hospitalization. The incident was attributed to the nurse being distracted while preparing medications and not following established clinical standards and facility policy for safe medication administration.
Failure to Maintain a Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for two residents, as observed during a survey. Resident #12, who has moderate cognitive impairment due to Multiple Sclerosis and other conditions, was found in a room where the bottom trim baseboard was coming apart from the wall, with gouges in the paint and drywall. Blue tape was used to cover these gouges, and Resident #12 was unsure how long the tape had been there. Similarly, Resident #7, who has severe cognitive impairment due to Dementia and other health issues, was found in a room with multiple tears in the paint and drywall behind the headboard of their bed. The facility's administrator confirmed that the conditions in both rooms did not reflect a homelike environment, acknowledging the need for repairs.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to develop Enhanced Barrier Precautions (EBP) on the comprehensive care plans for three residents with indwelling urinary devices. Resident #36, who was cognitively intact, had a suprapubic catheter for a neurogenic bladder, but the care plan did not include EBP. Observations revealed no EBP signage or Personal Protective Equipment (PPE) available in or outside the resident's room. Interviews with staff, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), indicated a lack of awareness regarding the need for EBP during catheter care. Resident #12, with moderate cognitive impairment, also had an indwelling catheter for a neurogenic bladder, yet EBP was not included in the care plan. Observations confirmed the absence of EBP signage and PPE. Interviews with the Registered Nurse (RN) House Supervisor and CNAs revealed that the resident was not placed in EBP, and staff only wore gloves during catheter care, indicating a lack of implementation and awareness of EBP requirements. Resident #24, with moderate cognitive impairment and a suprapubic catheter for neurogenic bladder, similarly lacked EBP in the care plan. Observations showed no EBP signage or PPE, and interviews with the Infection Preventionist and an LPN confirmed the absence of EBP implementation for this resident. The Infection Preventionist acknowledged that residents with indwelling devices should be placed on EBP, but this was not done for the three residents in question.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with indwelling devices, as required by their infection prevention and control program. The facility's policy mandates the use of gowns and gloves during high-contact activities for residents with indwelling medical devices, regardless of infection or colonization status. However, observations and interviews revealed that staff were not following these precautions for residents with suprapubic and indwelling catheters. Resident #36, who has a suprapubic catheter due to neurogenic bladder, did not have EBP signage or personal protective equipment (PPE) available in or outside their room. Interviews with the resident and staff, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), indicated that only gloves were used during catheter care, and there was a lack of awareness about the need for EBP. Similarly, Resident #12, with an indwelling catheter, and Resident #24, with a suprapubic catheter, also lacked EBP signage and PPE. Interviews with staff, including a Registered Nurse (RN) House Supervisor, CNAs, and the Infection Preventionist, confirmed that EBP was not implemented for these residents. The staff were unaware of the requirement for additional PPE beyond gloves during catheter care, indicating a systemic failure to adhere to the facility's infection control policy.
Inaccurate MDS Assessment for Resident with Fall Incident
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident, identified as Resident #6, as required by the Centers for Medicare and Medicaid Services (CMS) guidelines. The facility's policy mandates that MDS assessments be completed based on information from various sources, including the resident, family, physician, caregivers, and clinical assessments. These assessments are crucial for developing a comprehensive plan of care. However, a review of the quarterly MDS assessment for Resident #6, dated January 25, 2024, revealed that no falls were documented since the prior assessment, despite evidence to the contrary. Resident #6 was admitted with multiple diagnoses, including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Bipolar Disorder, Weakness, Vascular Dementia, and Adult Failure to Thrive. The comprehensive care plan for this resident, revised on December 27, 2023, indicated a potential for falls, with interventions such as using a wedge for support. On the same day, the resident was found on the floor beside the bed and was transported to the emergency department for further evaluation. During an interview, the Interim MDS Coordinator confirmed that the resident had experienced a fall on December 27, 2023, and acknowledged the inaccuracy in the MDS assessment dated January 25, 2024.
Failure to Remove Discontinued Narcotics from Inventory
Penalty
Summary
The facility failed to ensure that discontinued narcotics were removed from inventory in a timely manner, leading to discrepancies in medication documentation for a resident. According to the facility's policy on discarding and destroying medications, unused controlled substances should be counted each shift and marked with a red X until properly disposed of. However, the facility did not adhere to this policy for a resident who was prescribed Percocet, a narcotic for pain, which was discontinued but not removed from the inventory. The resident, who had severe cognitive impairment, was admitted with diagnoses including Alzheimer's Disease and Mood Disorder. Despite the discontinuation of Percocet on a specific date, the medication was documented as withdrawn from inventory by an RN five days later, with no corresponding administration record. The resident did not report any pain or request for medication, and there was no recollection of the RN's presence in the room, raising concerns about potential medication diversion. The facility's investigation revealed that the RN involved did not respond to multiple attempts to discuss the irregularities. The DON confirmed that the failure to remove the discontinued medication from the cart led to the incident. The facility concluded that had the medication been removed and destroyed as per policy, the discrepancy would not have occurred.
Incomplete Medical Record Documentation for Resident Fall
Penalty
Summary
The facility failed to maintain a complete medical record for a resident, specifically regarding an unwitnessed fall that occurred on January 25, 2024. The facility's policy requires that any changes in a resident's condition, such as falls, be documented in the medical record. However, the fall was not recorded at the time of occurrence. The resident, who had a history of falls and was diagnosed with muscle weakness, dementia, and general anxiety disorder, was found sitting on the floor by a clothes closet after the fall. The incident was not documented by the responsible nurse, and the facility was only made aware of the fall after an Environmental Services employee reported a new skin injury on the resident. Interviews revealed that the fall was not documented by an agency nurse, who was later terminated. The Director of Nursing confirmed that the nurse did not follow the facility's policy by failing to chart the fall in the medical record. The incident was discovered after a Licensed Practical Nurse found a skin tear on the resident's forearm, which was also not documented. The facility initiated an investigation into the injury of unknown origin after being alerted by the Environmental Services employee.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Red Bank | 2.7 mi | — | 0 | 0 |
| Siskin Subacute West | 6.6 mi | — | 0 | 0 |
| Life Care Center Of Hixson | 8 mi | — | 0 | 0 |
| Nhc Healthcare, Chattanooga | 8.3 mi | — | 0 | 0 |
| Nhc Healthcare Rossville | 11.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.