Shannondale Of Maryville Health Care Center

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Based on facility policy review, facility documentation review, and interview, the facility failed to maintain a grievance log for the required period of 3 years.The findings include: Review of the facility's policy titled, Grievances, dated 7/1/2009, revealed .Grievance Log will be kept for a period of three (3) years. The log shall contain evidence of the resolution and grievances . Review of the facility's Concern log revealed the facility had record of grievances from July 2024 - August 2025. There was no log available for grievances prior to July 2024. During an interview on 9/3/2025 at 11:44 AM, the Administrator confirmed no grievance log was available in the facility prior to July 2024. The facility changed administration and ownership in June

1. 2024. The Administrator confirmed the grievance log was to be kept and available for review in the facility

for a period of 3 years. During an interview on 9/3/2025 at 11:48 AM, the Case Manager stated she was the current grievance official at the facility. The Case Manager had been the grievance official since the facility changed ownership in June 2024. The Case Manager stated she was unaware where the grievance log was prior to July 2024. The Case Manager confirmed there was no grievance log available prior to July 2024 and that grievance logs were to be kept for a period of 3 years. The Case Manager stated she had reached out to the former grievance official who no longer worked at the facility who was unaware where

the grievance logs were located.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Shannondale of Maryville Health Care Center

803 Shannondale Way Maryville, TN 37803

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

allegation and stated there was no notification to law enforcement, Adult Protective Services (APS) .that I have located . Notifications to law enforcement and APS were to be documented and included in the facility investigation documentation. During a telephone interview on 9/4/2025 at 10:28 AM, the former DON stated

she did not recall the allegation of sexual abuse for Resident #3. The former DON stated she would have been responsible for abuse investigations, and it would have included notifications to the family, physician, state agency, Adult Protective Services (APS) and police. The former DON stated all investigations were left

in her desk drawer when she left the facility. During an interview on 9/3/2025 at 4:45 PM, the DON stated

she was unaware if the former administration had notified law enforcement or Adult Protective Services (APS) of Resident #3's sexual abuse allegation. The DON stated she called the local police department on 9/3/2025 and there was no police report related to Resident #3. The DON stated the facility had contacted APS on 9/3/2025 and left a message to determine if they had been notified of the allegation. The DON confirmed there was no documentation available at the facility to indicate law enforcement or APS had been notified of the allegation and confirmed both agencies should have been notified of the allegation and there should be evidence of the notification. During a telephone interview on 9/4/2025 at 1:11 PM, the local police department stated they were unable to locate a report for Resident #3. During a telephone interview

on 9/4/2025 at 1:28 PM, the APS intake counselor stated she was unable to locate any reports related to Resident #3. During a telephone interview on 9/4/2025 at 1:47 PM, the APS Supervisor stated she had checked the state and county records and there had been no reports to APS regarding Resident #3.

Medical record review revealed Resident #8 was admitted to the facility on [DATE REDACTED] with diagnoses including Dementia, Major Depressive Disorder, Adjustment Disorder and Delusion Disorder. Medical record review of Resident #8's current comprehensive care plan dated 5/30/2022 revealed .Verbally abusive behavior .Converse with others without swearing or berating .is experiencing alteration in mood AEB (as evidence by) .c/o (complaint of) people coming into room and stealing . Each problem identified by the facility had appropriate pharmacological and non-pharmacological interventions implemented. Review of a Psychiatric Nurse's note for Resident #8 dated 7/13/2023, revealed the resident was seen for psychiatric evaluation for .irritability, dementia, frustration previous gpsych (geri-psychiatric) admits 071323 (7/13/2023) Administration requests consult r/t (related to) ongoing lability . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED], revealed Resident #8 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. The resident required assistance from 1 or more staff members for activities of daily living (ADL's). During an interview on 9/4/2025 at 3:16 PM, the Administrator and DON confirmed there was no investigation documentation for allegations of abuse reported to the state agency or APS for Residents #3 and #8. The Administrator and DON were unaware what the investigations for Residents #3 and #8 included because no documentation of

the investigation was retained by the previous administration. The Administrator stated all allegations of abuse were to be reported to the state agency, law enforcement, and APS within 2 hours of allegation. The Administrator confirmed she was unaware if the allegations had been reported because no documentation was available from the previous administration.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Shannondale of Maryville Health Care Center

803 Shannondale Way Maryville, TN 37803

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

assistance from 1 or more staff members for activities of daily living (ADL's). During an interview on 9/4/2025 at 3:16 PM, the Administrator and DON confirmed there was no investigation documentation for allegations of abuse reported to the state agency for Residents #3 and #8. The Administrator confirmed a thorough investigation was to be completed for all abuse allegations/state reportable incidents and should include resident interview related to the allegation, witness statements, other resident interviews/skin assessments, physical assessments, physician notification, family notification, and notifications to other agencies. The Administrator and DON were unaware what the investigations for Residents #3 and #8 included because no documentation of the investigation was retained by the previous administration. The Administrator confirmed abuse investigations were to be documented and retained in the facility. The Administrator confirmed they were unable to determine if a thorough investigation was completed because there was no investigation documentation available for Residents #3 and #8.

Event ID:

Facility ID:

If continuation sheet