Rocky Top Care Center: Resident-on-Resident Assault - TN
The incident happened on August 12, 2024. Federal inspectors documented it ten days later, on August 22, as part of a health inspection that cited the facility for failing to protect residents from abuse.
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See the Derila PillowLPN L was in the dining room that morning, helping residents with hand hygiene, when Resident 338 flagged her down. Resident 13 had already hit Resident 54 twice in the forehead. By the time LPN L looked up, Resident 13 was standing over Resident 54, fist raised, not finished.
She moved immediately. CNA N was also present and helped redirect Resident 13 away. When LPN L asked Resident 13 why he had hit Resident 54, he told her it was because he wanted to and that he had his reasons.
She then turned to Resident 54. She asked him if someone had hit him. He told her yes, somewhere on the face. Both residents were assessed for injuries. None were observed.
LPN L confirmed to inspectors what she had seen and what it was: a resident-to-resident altercation that resulted in physical abuse.
The psychiatric nurse practitioner assigned to the facility was reached by telephone three days later, on August 15. She said she was aware of what had happened on August 12. She said immediate interventions had been initiated and described them as successful in preventing a recurrence. She said it was unknown whether Resident 13 had been triggered by Resident 54, because of Resident 13's cognition. She, too, called it physical abuse.
That word, abuse, appears twice in the inspection record, once from the nurse who witnessed it and once from the psychiatric clinician who evaluated it afterward. Neither hedged.
What the record does not contain is any explanation of how two residents ended up in proximity in a dining room when at least one of them posed a risk of striking the other. It does not describe what, if anything, was known about Resident 13's history of aggression before August 12. It does not say whether Resident 54 had any cognitive impairment that affected his ability to protect himself or move away. The inspection narrative is brief. Four paragraphs. The harm level was classified as minimal harm or potential for actual harm, which is the lower end of the federal scale.
That classification reflects the absence of visible injury, not the absence of violence. Resident 54 was hit in the head twice by a man whose fist was still raised when staff arrived. The fact that no bruise was found does not change what happened to him.
The psychiatric nurse practitioner's statement that the interventions have been "successful" was made three days after the assault. The inspection itself came ten days after that. Whether those interventions remained in place, and whether Resident 54 continued to share common spaces with Resident 13, is not addressed in the record.
Rocky Top Care Center is located at 204 Industrial Park Road in Rocky Top, Tennessee, a small city in Campbell County in the northeastern part of the state. The facility's CMS identification number is 445259.
The dining room is one of the few places in a nursing home where residents with different care needs and different behavioral histories are regularly placed in close proximity to one another. It is also one of the places where staffing is stretched thinnest, with aides managing hygiene assistance, meal service, and supervision simultaneously. LPN L was helping residents wash their hands when the first punch landed. She did not see it. Resident 338 had to tell her.
Resident 13, by his own account, hit Resident 54 because he wanted to. That explanation, offered without apparent remorse and recorded in a federal inspection document, is the clearest statement in the record about what kind of risk Resident 54 was living alongside.
The psychiatric nurse practitioner said it was unknown whether Resident 13 was triggered by Resident 54. That framing, centered on what provoked the aggressor, is a clinical one. It is useful for treatment planning. It does not address what Resident 54 experienced: two blows to the head from a man who was still poised to deliver a third when a nurse finally reached them.
Resident 54 answered LPN L's questions after the assault. He confirmed he had been hit. He located the impact somewhere on his face. The record does not say whether he was frightened, whether he understood what had happened, or whether he had any way to have avoided it. His cognition is not described. His history at the facility is not described. He appears in this record only as the person who was struck.
The federal deficiency cited in this inspection falls under the abuse prevention requirements that nursing homes participating in Medicare and Medicaid must meet. The plan of correction is not included in the inspection document. Inspectors directed anyone seeking that information to contact the facility or the state survey agency directly.
What the record leaves behind is a dining room on a Monday morning in August, a man hit twice in the head before anyone could stop it, and a nurse who arrived to find the attacker's fist still in the air.
Resident 54 told her yes, somewhere on the face.
That is where the record ends.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rocky Top Care Center from 2024-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 14, 2026 · Our methodology
ROCKY TOP CARE CENTER in ROCKY TOP, TN was cited for violations during a health inspection on August 22, 2024.
The incident happened on August 12, 2024.
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.