Shannondale: Sexual Abuse Reports Never Sent to Police - TN
The current director of nursing discovered the problem during a September inspection when she called local police about Resident #3's case. No report existed.
"There was no police report related to Resident #3," the director told inspectors on September 3rd. She had contacted Adult Protective Services the same day and left a message to determine if they had been notified of the allegation.
They hadn't been.
During telephone interviews on September 4th, both agencies confirmed they had no records. The local police department was "unable to locate a report for Resident #3." The APS intake counselor "was unable to locate any reports related to Resident #3." An APS supervisor checked state and county records and found "there had been no reports to APS regarding Resident #3."
The former director of nursing, reached by phone on September 4th at 10:28 AM, told inspectors she "did not recall the allegation of sexual abuse for Resident #3." She said she would have been responsible for abuse investigations, which should have included notifications to the family, physician, state agency, Adult Protective Services and police.
All her investigation files were left in her desk drawer when she departed.
The current administrator and director of nursing confirmed they had no investigation documentation for abuse allegations involving either Resident #3 or Resident #8. They were "unaware what the investigations for Residents #3 and #8 included because no documentation of the investigation was retained by the previous administration."
Resident #8's medical records reveal the complexity of cases the facility was handling. Admitted with diagnoses including dementia, major depressive disorder, adjustment disorder and delusion disorder, the resident exhibited "verbally abusive behavior" and complained "of people coming into room and stealing."
A psychiatric nurse evaluated Resident #8 on July 13, 2023, for "irritability, dementia, frustration" with a note that administration had requested the consultation "related to ongoing lability." The resident scored a 3 on the Brief Interview for Mental Status assessment, indicating severe cognitive impairment, and required assistance from one or more staff members for activities of daily living.
The facility's comprehensive care plan for Resident #8, dated May 30, 2022, documented efforts to address the resident's behavioral issues. Goals included helping the resident "converse with others without swearing or berating" and managing mood alterations. Both pharmacological and non-pharmacological interventions had been implemented.
But when allegations of abuse arose involving this vulnerable resident, no evidence exists that proper authorities were contacted.
Federal regulations require nursing homes to report allegations of abuse to the state agency, law enforcement and Adult Protective Services within two hours. The current administrator confirmed this requirement during her September 4th interview with inspectors, stating she was "unaware if the allegations had been reported because no documentation was available from the previous administration."
The missing documentation represents more than administrative oversight. Both residents had severe cognitive impairments that made them particularly vulnerable to abuse and unable to advocate for themselves or provide reliable testimony about incidents.
Resident #3's case remains largely undocumented in the inspection report, with only references to sexual abuse allegations that were never properly investigated or reported. The absence of police reports or Adult Protective Services involvement means no independent investigation occurred to determine what happened or ensure the resident's safety.
The facility's failure extended beyond individual cases to systemic breakdowns in mandatory reporting procedures. When abuse allegations surface in nursing homes, the two-hour reporting requirement exists specifically because residents with dementia and other cognitive impairments cannot protect themselves.
The current administration inherited a facility where serious allegations had been handled without creating the paper trail required by federal law. No documentation existed to show whether families had been notified, whether medical evaluations had been conducted, or whether any steps had been taken to prevent further incidents.
The former director of nursing's statement that she left "all investigations in her desk drawer" when she departed suggests a casual approach to documentation that violated federal requirements for maintaining and preserving records of abuse investigations.
Without police involvement, no criminal investigation occurred. Without Adult Protective Services notification, no independent welfare check was conducted. Without proper documentation, the current administration cannot determine what actually happened or whether appropriate protective measures were implemented.
The inspection found that both residents required significant assistance with daily activities and had documented behavioral and psychological symptoms that made them particularly vulnerable. Resident #8's care plan specifically addressed verbally abusive behavior and mood alterations, indicating staff awareness of the resident's psychological state.
The psychiatric evaluation noting "ongoing lability" suggests Resident #8 experienced emotional instability that could have made the resident both a target for abuse and unable to provide coherent reports about incidents.
The facility's current leadership acknowledged the severity of the documentation failures during interviews with inspectors. They confirmed that all allegations of abuse should have been reported to multiple agencies within two hours and that evidence of those notifications should have been retained.
The administrator's statement that she was "unaware if the allegations had been reported because no documentation was available" highlights the complete breakdown in required procedures that occurred under the previous administration.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to few residents. However, the classification reflects the documentation failure rather than the underlying abuse allegations, which remain uninvestigated due to the reporting failures.
The case illustrates how administrative turnover in nursing homes can create gaps in accountability when proper procedures are not followed. Residents with severe cognitive impairments depend entirely on facility staff to recognize, report and investigate allegations of abuse.
When that system fails, as it did at Shannondale of Maryville, vulnerable residents are left without the protections federal law requires. The missing investigation files mean no one can determine whether the alleged abuse actually occurred, whether it was properly addressed, or whether similar incidents might happen again.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shannondale of Maryville Health Care Center from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
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
SHANNONDALE OF MARYVILLE HEALTH CARE CENTER in MARYVILLE, TN was cited for abuse-related violations during a health inspection on September 4, 2025.
The current director of nursing discovered the problem during a September inspection when she called local police about Resident #3's case.
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.