Inspection Report

Summit View of Rocky Top: Staffing Crisis, Hygiene TN

October 31, 2025

Rocky Top, TN

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ROCKY TOP, TN - A federal inspection at Summit View of Rocky Top nursing home revealed severe staffing deficiencies that resulted in dozens of missed showers for residents and compromised care standards during a two-week period in August 2024.

Widespread Shower Schedule Failures

Federal inspectors documented systematic failures in providing basic hygiene care to residents between August 1-16, 2024. Five residents collectively missed 18 scheduled showers during this timeframe, with some residents going without proper bathing for extended periods. Resident #39 and Resident #49 each missed five scheduled showers, while Resident #77 missed four showers, and Resident #33 missed three scheduled baths.

The violations occurred despite federal regulations requiring nursing homes to maintain adequate staffing levels to meet all resident care needs, including personal hygiene assistance. Regular bathing is considered a fundamental aspect of resident dignity and health maintenance in long-term care settings.

During evening shift interviews, Licensed Practical Nurse E revealed the extent of the staffing crisis. She reported working 12-hour overnight shifts (6:00 PM to 6:00 AM) responsible for 50 residents with only one certified nursing assistant and two nurses total. "There were times when scheduled showers were not completed due to not enough staff," she told inspectors.

Dangerous Staffing Ratios Compromise Care

The inspection revealed that on August 8, 2024, staffing levels dropped to critically low numbers, with only one nurse and one CNA covering 50 residents during the entire 12-hour night shift. This ratio falls far below industry standards for safe patient care in nursing home environments.

Licensed Practical Nurse F, who worked the facility's east hallway, corroborated these concerns during her interview. She confirmed that scheduled showers regularly went uncompleted due to insufficient staffing levels, creating a pattern of neglected personal care needs rather than isolated incidents.

Personal hygiene care serves multiple critical health functions beyond basic cleanliness. Regular bathing helps prevent skin breakdown, reduces infection risk, maintains circulation, and supports mental health and dignity. When residents miss multiple scheduled showers, they face increased risks of urinary tract infections, skin conditions, and psychological distress from inadequate personal care.

Administrative Awareness Without Action

The inspection revealed that facility leadership was aware of the staffing problems but failed to take adequate corrective measures. The Director of Nursing Services acknowledged receiving "voiced concerns from CNAs and nurses regarding low staffing and scheduled showers not being completed."

Most concerning was the Administrator's admission of knowledge without intervention. During his interview, he stated "I do know it [staffing concerns] exists" and confirmed awareness that residents had missed scheduled showers. However, nursing staff reported that the Administrator had not inquired whether resident needs were being met or if staff could complete their assigned duties.

This disconnect between administrative awareness and corrective action represents a fundamental failure in facility management. Federal regulations require nursing home administrators to ensure adequate staffing levels and to address known deficiencies that affect resident care quality.

Medical and Safety Implications

The staffing shortages created a cascade of care failures beyond missed showers. Inspectors noted that insufficient staffing also affected the facility's ability to provide transportation for scheduled outpatient physician appointments, potentially delaying necessary medical care for residents.

Proper hygiene care is particularly crucial for elderly nursing home residents who may have compromised immune systems, mobility limitations, and chronic health conditions. Extended periods without adequate bathing can lead to skin irritation, bacterial overgrowth, and increased susceptibility to infections. For residents with incontinence issues, regular cleaning becomes even more critical to prevent serious complications.

The staffing ratios documented during the inspection create unsafe conditions where nursing staff cannot adequately monitor residents, respond to emergencies, or provide basic care needs. When one CNA is responsible for assisting 50 residents with personal care, meals, and mobility needs during a 12-hour shift, quality care becomes impossible to maintain.

Additional Issues Identified

The inspection documented broader systemic problems stemming from inadequate staffing levels. Beyond the missed shower violations, the facility failed to ensure sufficient staff coverage for essential resident services including medical appointment transportation and comprehensive daily care needs.

The facility received citations for failing to maintain expected staffing levels required to meet resident care needs and for administrative failures in addressing known staffing concerns. Both the Director of Nursing Services and Administrator ultimately acknowledged that the facility had not maintained sufficient staffing levels to provide required resident care services.

This inspection highlights ongoing challenges in nursing home staffing that affect thousands of facilities nationwide, where inadequate staffing ratios continue to compromise basic resident care and dignity.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Summit View of Rocky Top from 2024-08-22 including all violations, facility responses, and corrective action plans.

Additional Resources

Editorial Standards

Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).

Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.

Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.

Last verified: June 20, 2026 · Our methodology

Quick Answer

ROCKY TOP CARE CENTER in ROCKY TOP, TN was cited for violations during a health inspection on August 22, 2024.

**Five residents collectively missed 18 scheduled showers** during this timeframe, with some residents going without proper bathing for extended periods.

Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.

Frequently Asked Questions

What happened at ROCKY TOP CARE CENTER?

**Five residents collectively missed 18 scheduled showers** during this timeframe, with some residents going without proper bathing for extended periods.

How serious are these violations?

Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in ROCKY TOP, TN, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from ROCKY TOP CARE CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 445259.

Has this facility had violations before?

To check ROCKY TOP CARE CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.