The first official performance audit of the Tennessee Health Facilities Commission, which is required to survey nursing homes and assisted care living facilities every 15 months to ensure they continue to meet state and federal health
and safety standards, found that from July 1, 2022, through April 17, 2025, the Commission performed 16,629 complaint investigations, 79% of which were related to nursing homes and assisted care living facilities. “We found that staff did not complete surveys for 341 facilities (51%) within the 15-month timeframe required by federal and state
requirements. Alarmingly, 22 providers had not been surveyed in at least 60 months, indicating substantial lapses in meeting timeliness requirements.”
In July 2022, the Commission took over federal and state survey responsibilities from another state entity. At that time, they inherited a backlog of 176 overdue federal nursing home surveys. By April 2025, this backlog increased to 192.
From July 1, 2022 through April 17, 2025, the Commission received 13,096 complaints related to nursing homes and assisted care living facilities. Management indicated that complaint volume and severity affect the scheduling and staffing of facility surveys. “However, our analysis revealed that staff did not investigate 5,534 of the 13,096 complaints (42%) within the federally required timeframes. All these late complaints were classified as either immediate jeopardy, high risk but not immediate jeopardy, or medium risk but not immediate jeopardy.” As of April 17, 2025, management had not started the investigation of 4,756 complaints, which represents management’s complaint backlog.
“Even though management developed a plan for federal surveys, they have not developed a detailed plan to address outstanding state licensure surveys, especially for assisted care living facilities, including the complaints they have received. Many of the complaints were received after the commission became responsible for investigating them.
Until management can eliminate the backlog and catch up on all surveys and complaint investigations, individuals receiving services at these facilities will continue to be at risk.”
Conclusions
“Based on our work, we found that the majority of surveys were not completed on time, and management has not developed an effective process. Additionally, management did not design internal controls to ensure the completeness of the survey data.”
“Based on our work, we found that management is struggling to begin and complete complaint investigations within the required timeframes. Currently, the commission has a backlog of complaints for nursing homes and assisted care living facilities.”
“The commission was not able to resolve the backlog of surveys for nursing homes and now has a backlog of surveys for assisted care living facilities. Management is required by statute to resolve the survey backlog by December 31, 2026, and may be challenged to eliminate it by the deadline.”
If you or a loved one suffered injuries (or worse) while a resident of a nursing home in Tennessee or in another U.S. state due to nursing home neglect, nursing home negligence, nursing home abuse, a nursing home fall, or nursing home understaffing, you should promptly contact a nursing home claim attorney in Tennessee or in your state who may investigate your nursing home claim for you and file a nursing home injury claim on your behalf, if appropriate.
Visit our website to be connected with medical malpractice lawyers (nursing home claim lawyers) in your U.S. state who may assist you with your nursing home claim, or call us toll-free in the United States at 800-295-3959.
Turn to us when you don’t know where to turn.
