Gallaway Health and Rehab: Care Plan Failures - TN
The resident, identified in inspection records as Resident 3, could not bear weight. A transfer for someone in that condition requires two staff members and a mechanical lift. That is not a judgment call. It is the kind of thing that gets written into a care plan so that whoever shows up for the night shift knows what they are walking into.
No care plan existed for Resident 3.
Federal inspectors from the Centers for Medicare and Medicaid Services visited the facility on August 27, 2025, following a complaint. What they found was a gap between what the facility knew about this resident and what it had done with that knowledge.
The nursing assistant, identified in the report as CNA BB, told inspectors she had moved Resident 3 multiple times during the night, pulling her up from a mat on the floor and returning her to bed, each time without a second staff member and without a mechanical lift. When asked whether she knew what the resident required for transfers, CNA BB said, "I really don't know what she required, I was told it was normal to leave her on the mat all night."
That answer contains two separate problems. The first is that CNA BB did not know the resident's transfer requirements. The second is that someone had told her it was normal to leave a non-weight-bearing resident on a floor mat through the night.
CNA BB confirmed she had not reported the falls to the licensed practical nurse on duty, identified as LPN Y. Her explanation was direct: "No, I figured she knew because she was sitting in the hall outside of her room all night. I figured it was something she does all the time, since the nurse didn't say anything."
LPN Y was sitting in the hallway outside Resident 3's room. Whether the nurse was aware of what was happening inside that room, and whether she said anything or did anything in response, the inspection report does not say. What it says is that CNA BB interpreted the nurse's silence as confirmation that nothing was wrong.
That is what an absent care plan produces. It does not just leave a nursing assistant without instructions. It leaves her without a framework for recognizing that what she is doing might be harmful. If nobody has written down that this resident needs two people and a mechanical lift, then moving her alone feels like improvisation rather than a violation.
The MDS Coordinator, interviewed by inspectors the same afternoon, confirmed the failure plainly. She reviewed Resident 3's comprehensive care plan and told inspectors a care plan had not been developed or implemented for transfer assistance. She confirmed Resident 3 was unable to bear weight and should have had a care plan specifying a two-person assist with a mechanical lift.
The facility's own standard, the MDS Coordinator said, requires a two-person assist with a mechanical lift for any resident who cannot bear weight. That standard existed. It just had not been applied to this resident.
CMS cited the facility under F0656, which covers the development and implementation of comprehensive care plans. The citation was tagged at a level of minimal harm or potential for actual harm, affecting a few residents.
The citation level reflects the regulatory floor, not necessarily the physical reality of what Resident 3 experienced on the floor of her room. Moving a non-weight-bearing person without a lift, multiple times, through the course of a night, carries real risk of injury. The inspection report does not describe whether she was hurt.
What it describes is a resident on a mat, a nursing assistant who did not know what the resident required, a nurse sitting in the hallway, and a care plan that was never written.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gallaway Health and Rehab from 2025-08-27 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 2, 2026 · Our methodology
GALLAWAY HEALTH AND REHAB in GALLAWAY, TN was cited for violations during a health inspection on August 27, 2025.
The resident, identified in inspection records as Resident 3, could not bear weight.
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.