Greystone Health Care Center
181 Dunlap Road, Blountville, TN 37617 · For profit - Limited Liability company · 160 certified beds · (423) 323-7112 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2024
- it has a citation for mishandling residents’ money or property (F0565)
- it has 1 actual-harm citation
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $15,041 in federal fines (most recent 2024-07-31)
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.6% | 14.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.6% | 6.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.5% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.7% | 13.8% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.7% | 3.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 16.1% | 17.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 49.9% | 31.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.9% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.1% | 5.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.2% | 20.0% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.1% | 16.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.2% | 1.7% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 76.4% | 79.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 29.8% | 22.6% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.1% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.02 | 1.67 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.53 | 1.56 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
33.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 33.9%CMS range 21.4–51.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 7.3–16.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 90.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 14.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.31 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 160 beds and averages 107.5 residents a day — about 67% occupied, or roughly 52 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.17 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.41 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.69 hrs/resident/day on weekends vs 4.36 on weekdays — 15% thinner on weekends. RN hours go from 0.72 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · G2024-07-31 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, police report review, facility investigation review, and interview the facility failed to protect the residents' right to be free from sexual abuse and physical abuse by another resident for 4 of 14 (Resident #11, #17, #18, and #5) sampled residents reviewed for abuse. On 6/25/2024, Resident #9 was observed with his hand on Resident #11's pelvic region and Resident #11 was observed shaking his head no. On 11/26/2023, Resident #18 grabbed Resident #17's arm resulting in a scratch to her finger and Resident #17 scratched Resident #18 on the face when Resident #18 entered Resident #17's room. On 3/15/2024, Resident #6 hit Resident #5 with a soda can in her chest area. The facility's failure to protect the residents' right to be free from abuse resulted in actual harm for Resident #11, #17, and #18. The findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation, revised 1/10/2024, revealed .it is the policy of this facility to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-14 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview the facility failed to ensure resident's right to retain personal possessions for 1 resident (Resident #1) of 3 residents reviewed. The findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Tracheostomy, Dependence on Ventilator, Gastrostomy Status, Need for Assistance with Personal Care. Review of a Minimum Data Set (MDS) assessment for Resident #1 revealed a Discharge return anticipated MDS assessment was completed on 1/29/2025 and an entry MDS assessment was completed on 3/18/2025. Review of nurse's progress notes for Resident #1 revealed the resident was transferred to the hospital on 1/29/2025 and returned to the facility on 3/18/2025. Review of an admission MDS assessment dated [DATE] revealed Resident #1 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-07 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview the facility failed to ensure resident's right to retain personal possessions for 1 resident (Resident #1) of 3 residents reviewed. The findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Tracheostomy, Dependence on Ventilator, Gastrostomy Status, Need for Assistance with Personal Care. Review of a Minimum Data Set (MDS) assessment for Resident #1 revealed a Discharge return anticipated MDS assessment was completed on 1/29/2025 and an entry MDS assessment was completed on 3/18/2025. Review of nurse's progress notes for Resident #1 revealed the resident was transferred to the hospital on 1/29/2025 and returned to the facility on 3/18/2025. Review of an admission MDS assessment dated [DATE] revealed Resident #1 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-07 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documentation review, observation, and interview the facility failed to use a disinfectant according to the manufacturer's instructions on 1 of 3 hallways observed for disinfectant use to prevent the spread of candida auris and other infectios organisms. The findings include: Review of facility undated document titled, Healthcare SEVICES GROUP, revealed .PURPOSE: To teach environmental Services employees the proper cleaning method to sanitize .any area in a healthcare facility .when using cleaning products always refer to the manufacturer's recommended dwell time. Dwell time .is how long a chemical needs to be in contact with the surface in order to effectively sanitize or disinfect . Review of facility undated document titled .VIRASEPT . revealed .is a .Detergent-Disinfectant .Effective in 4 minutes .Apply Virasept with a coarse trigger sprayer, cloth .or by soaking to thoroughly wet surface .Allow surface to remain wet for at least 4 minutes . During an observation on 4/2/2025 at 2:30 PM, on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-10-30 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observations, and interviews, the facility failed to ensure daily staff posting information included the resident census, the facility name, and actual number of hours worked by Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNA) on 3 of 3 days reviewed for staff postings. The findings include: Review of the facility policy titled, Facility Required Postings, revised on 1/1/2022, revealed .The facility will post required postings .staffing information . Review of the Daily Staffing Sheets dated 10/28/2024-10/30/2024 revealed the following: The resident census and facility name was not listed for 3 days on the Daily Posted Staffing Sheets from 10/28/2024-10/30/2024. The RN hours, LPN hours, and CNA hours were not documented on the Daily Posted Staffing Sheets for 3 days from 10/28/2024-10/30/2024. During an interview on 10/30/2024 at 8:45 AM, the Staffing/Central Supply Coordinator confirmed the Daily Posted Staffing Sheets on 10/28/2024-10/30/2024 did not include the resident census, the facility name, or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-10-30 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observations, and interviews, the facility failed to maintain kitchen equipment in a sanitary condition, ensure spices were properly sealed, and failed to discard expired food which had the potential to affect 92 of 95 residents. The findings include: Review of the facility's policy titled, Environment, revised 9/2017, revealed .Dining Services Director will ensure kitchen is maintained in a clean sanitary manner, including floors, walls . Review of the facility's policy titled, Food Storage: Dry Goods, revised 2/2023, revealed .packaged .foods items will be kept .properly sealed . During an observation of the food preparation area on 10/28/2024 at 10:15 AM, with the Certified Dietary Manager (CDM), revealed the following: 1. 12-ounce bottle of salt and pepper seasoning salt was not sealed and available for use. 2. An unopened container of mild wing sauce, with an expiration date of 12/13/2023, available for use. 3. The area behind the deep fryer contained a greasy film with food particles. 4. The pipe under the dirty sink area actively dripping…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-30 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility document review, medical record review, and interviews, the facility failed to ensure Durable Power of Attorney (POA) documents were entered into the medical record for 2 residents (Residents #23 and #86) and failed to provide education regarding Advance Directives on admission for 6 residents (Residents #7, #8, #18, #37, #342 and #343). The findings include: Medical record review revealed Resident #23 was initially admitted to the facility on [DATE], and was most recently readmitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Seizures, Dementia, Depression, Bipolar Disorder, Anxiety, and Psychosis. Review of Resident #23's admission document dated 10/18/2018, titled, Advanced Directives and Other Legal Documents, revealed the resident had previously formulated a Durable Power of Attorney (POA) prior to admission to the facility and also revealed the POA signed legal documents on the behalf of the resident. Review of the resident's undated document titled admission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-30 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on facility policy review, observations, and interviews, the facility failed to ensure garbage and refuse were properly contained in 3 of 3 dumpsters. The findings include: Review of the facility's policy titled, Environment, revised 9/2017, revealed .trash will be properly disposed of in external receptacles (dumpsters) and the surrounding area will be free of debris . During an observation and interview on 10/28/2024 at 12:00 PM, the CDM confirmed the outside dumpster area contained three dumpsters for waste disposal and was observed with scattered refuse including used gloves, plastic medicine cups, plastic drinking cups, used wipes, drinking straws, plastic spoons, clear plastic bag filled with trash and was not maintained in a clean sanitary condition.
- Potential for harm · Ecited before2024-10-30 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility document review, observations, and interviews, the facility failed to offer 8 residents (Residents #33, #8, #34, #1, #63, #70, #292, and #24) with hand hygiene assistance before a lunch and breakfast meal on 2 of 3 hallways observed for meal service. The findings include: Review of the facility's document titled, Validation Checklist Hand Hygiene, undated, revealed .Purpose .to validate staff and residents are following hand hygiene protocols .Residents are offered hand hygiene prior to meals . During an observation on 10/28/2024 at 12:40 PM, on the 300 Hallway, Certified Nursing Assistant (CNA) F delivered the lunch meal tray to Resident #33 and did not offer hand hygiene assistance to the resident, prior to setting up the meal tray. During an interview on 10/28/2024 at 12:44 PM, CNA F confirmed hand hygiene assistance was not offered to Resident #33, prior to setting up the lunch meal tray. During an observation on 10/28/2024 at 12:52 PM, on the 200 Hallway, CNA G delivered the lunch meal tray to Resident #8 and did not offer hand hygiene assistance, prior to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, review of resident council minutes, and interview, the facility failed to ensure the residents' grievances related to adding more fresh fruits to meals and staff yelling and cursing in the hallways were promptly acted upon for 12 of 12 residents who attended the 10/29/2024 resident council meeting. The findings include: Review of the facility policy titled, Quality Assistance Procedure, revised 10/30/2023, revealed .The facility will provide a designated staff person who is approved by the resident or group .responsible for responding to written request .The facility will consider the views of a resident or family group and act upon .recommendations of such groups concerning issues of resident care and life in the facility . Review of Resident Council Minutes dated 8/16/2024, revealed .staff yelling and cursing in the hallways .would like new options on the .menu .tired of tropical fruit . During an interview on 10/29/2024 at 2:00 PM, residents participating in the resident council stated the prior concerns of staff disruptive yelling and cursing in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to provide 3 of 3 residents (Resident #12, Resident #400, and Resident #401) an Advanced Beneficiary Notice (ABN) after therapy services were discontinued, the resident remained in the facility for long-term care services, or was discharged from the facility. The facility's failure resulted in residents not being informed of the cost of therapy services if continued therapy services were desired which did not allow the residents to have an informed choice. The findings include: Review of the facility policy titled, Advance Beneficiary Notices, revised 10/30/2023, revealed .It is the policy of the facility to provide timely notices regarding Medicare eligibility and coverage .A notice of Medicare Non-Coverage .shall be issued to the resident/ representative when Medicare covered service(s) are ending, no matter if resident is leaving the facility or remaining in the facility . Medical record review revealed Resident #12 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · D2024-10-30 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observations, and interviews, the facility failed to provide effective housekeeping and maintenance services to ensure a safe, sanitary homelike environment for 1 resident (Resident #51) of 95 residents reviewed for a safe, sanitary homelike environment. The findings include: Review of the facility's policy titled, Safe and Homelike Environment, dated 1/1/2022, revealed .Environment refers to any environment .including .the resident's rooms. Sanitary includes .preventing the spread of disease-causing organisms. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary .environment .reporting lingering odors .to Housekeeping Department. Review of the facility's policy titled, Resident Refrigerators, dated 1/1/2022, revealed .Housekeeping staff shall record .temperatures daily on a temperature log .shall clean the refrigerator daily .discard any foods that are out of compliance leftovers shall be dated .foods with use by dates shall be discarded .…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-30 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASARR) for 2 residents (Resident #7 and #37). The findings include: Review of the facility's undated policy titled, PASARR - Pre-admission Screen and Resident Review, revealed .resident is admitted with a level diagnosis as indicated .review is required upon change in the residents condition . Medical record review revealed Resident #7 was admitted to the facility with diagnoses including Dementia, Bipolar Disorder, and Psychosis. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment, indicating moderate cognitive impairment. Medical record review revealed Resident #7's PASARR dated 9/29/2023, did not include a diagnosis of Post Traumatic Stress Disorder. Medical record review of the Psychiatric Evaluation dated 12/5/2023, revealed Resident #7 had a new…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observations, and interviews, the facility failed to maintain resident-care oxygen equipment in a clean and sanitary condition for 2 residents (Resident #23 and Resident #50) of 8 residents observed for oxygen use. The findings include: Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment, revised 10/23/2024, revealed .resident-care equipment will be cleaned .Cleaning .is the removal of visible soil from objects and surfaces .Direct care staff are responsible for cleaning single-resident equipment when visibly soiled . Medical record review revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Stroke, Dementia, Weakness, and Obstructive Sleep Apnea. During an observation on 10/28/2024 at 4:10 PM, a blue 5-liter oxygen concentrator was noted beside Resident #23's bed. The blue 5-liter oxygen concentrator was soiled with a tan brown-like substance covering the top…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure proper administration of an oral inhaler for 1 resident (Resident #52) of 4 residents observed for medication administration. The findings include: Review of the facility policy titled, Medication Administration .Oral Inhalations, dated 1/2023, revealed .To allow for safe, accurate, and effective administration of medication using an oral inhaler .Equipment .prescribed inhaler device .cup of water for rinsing mouth after steroid medication .ask resident to breathe out (do not exhale into the inhaler) .press down of the inhaler once to release medication as resident starts to breathe in slowly .hold breath for 5-10 seconds or as long as possible to allow medication to reach deeply into lungs . Medical record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Morbid Obesity, and Chronic Obstructive Pulmonary Disease. Review of a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observation, and interview, the facility failed to ensure medications were properly and securely stored in 1 of 3 medication storage rooms. The findings include: Review of the facility policy titled, Medication Storage, revised 1/30/2024, revealed .It is the policy of this facility to ensure all medications housed on our premises will be stored .to ensure proper .security .Narcotics and Controlled Substances: Schedule II drugs .are stored under double-lock and key . During an observation of the 2nd floor medication room with Registered Nurse (RN) A on 10/29/2024 at 9:45 AM, revealed 27 [name brand pain medication] (Schedule II pain medication) oral tablets stored in the 2nd floor medication room in an unlocked refrigerator. During an interview on 10/29/2024 at 9:47 AM, RN A confirmed the Schedule II pain medication was not stored under 2 locks, 1 lock on medication room door and 1 lock in the medication room refrigerator, and confirmed the refrigerator storing the narcotic pain medication was unlocked. During an interview on 10/30/2024 at 6:04 PM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-30 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observation, and interview, the facility failed to ensure a device containing electronic health records was secured and not visible to unauthorized persons for 1 medication cart of 6 medication carts observed. The findings include: Review of the facility policy titled, Electronic Protected Health Information (EPHI), revised 1/1/2022, revealed .ePHI is protected health information that is maintained in electronic media .Facility personnel shall ensure the confidentiality .availability of all ePHI that the facility creates .to protect .that data or information is not made available .to unauthorized persons .devices should always be locked when leaving the device so no unauthorized person can view .data . During an observation on 10/28/2024 at 10:55 AM, on the 100 Hallway, resident information was visible on the unattended and unlocked laptop screen attached to the 100 Hallway medication cart. During an interview on 10/28/2024 at 11:00 AM, Registered Nurse (RN) E confirmed resident information was visible to unathorized persons on the unattended and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation, and interview, the facility failed to ensure 1 resident's (Resident #50) call light was within reach out of 24 residents observed. The findings include: Review of the facility policy titled, Call Lights: Accessibility and Timely Response, revised 12/28/2023, revealed .Staff are educated in the proper use of the resident call system .ensuring resident access to the call light . Medical record review revealed resident #50 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of the Lung, Psychosis, and Diabetes. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #50 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment, indicating moderate cognitive impairment. The MDS revealed the resident was dependent with eating, toileting, and dressing. During an observation on 10/28/2024 at 12:45 PM, Resident #50 was observed asking for her nurse, the call light was in the bedside drawer with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy review, medical record review, and interview, the facility failed to ensure physician orders were followed for 1 resident (Resident #26) of 15 residents reviewed. The findings include: Review of the facility's policy titled, .Medication Errors ., revised 1/24/2024, revealed .facility shall ensure medications will be administered .according to physician's orders . Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including Acute Respiratory Failure, COPD, Major Depressive Disorder, and Dysphagia. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #26 scored a 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. Review of a physician's order for Resident #26 dated 6/28/2024, revealed an order for Lorazepam (Ativan- an antianxiety medication) 0.5 mg (milligrams) by mouth every 4 hours as needed for anxiety/seizure precaution for 14 days.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-10-13 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to maintain complete and accurate medical records for 2 residents (#45 and #68) of 25 residents reviewed for medical records. The findings include: Medical record review showed Resident #45 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Vascular Dementia, Coronary Artery Disease, Generalized Idiopathic Epilepticus, Dysphasia, Aphasia, Anxiety, and Major Depressive Disorder. Medical record review of Resident #45's Physician's orders, dated [DATE], showed: Full Code, Full Treatment. Medical record review showed Resident #45 had an Advance Directive for Health Care with the resident's name, full code choices, a Licensed Practical Nurse (LPN) signature, and no resident/resident representative signature or Physician's signature. Further review showed no Tennessee Physician Orders for Scope of Treatment (POST) form was included in the medical record. During an interview with the Director of Nursing (DON) on [DATE], at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-10-08 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to make a referral to the state-designated authority for a Level II Pre-admission Screening and Resident Review (PASARR) after newly identified serious mental disorders were diagnosed for 2 residents (#13, #32) of 11 residents reviewed for PASARR. The findings include: Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Dysthymic Disorder, Anxiety Disorder, and Hallucinations. Continued review revealed diagnosis of Psychosis was added on 2/22/19 and a diagnosis of Schizophrenia was added on 2/26/19. Medical record review of the most recent PASARR Level I Assessment was completed on 9/5/18. Continued review revealed a PASARR Level 2 Assessment was not completed for Resident #13 after the new diagnoses of Psychosis and Schizophrenia were added. Medical record review of a Significant Change Minimum Data Set (MDS) dated [DATE] revealed Resident #13 had diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-10-08 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview the facility failed to accurately screen and refer to the state-designated authority 1 resident (#72) of 11 residents reviewed with a serious mental disorder for a Pre-admission Screening and Resident Review (PASARR). The findings include: Review of the facility's policy PASRR (PASARR), dated 8/2014, revealed .A nursing facility must not admit, on or after January 1, 1989 any new residents with .mental disorder .schizophrenic .mood .severe anxiety disorder .psychotic disorder . Medical record review revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Status, Psychosis, General Anxiety Disorder, Bipolar Disorder, and Major Depressive Disorder. Medical record review of a PASARR Level I Screen Outcome, dated 8/11/19, revealed .mental health conditions .No mental health diagnosis is known or suspected . Medical record review of the Comprehensive Care Plan, dated 9/20/19 revealed the resident,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-10-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to administer oxygen therapy in accordance with Physician's Orders for 1 resident (#69) of 35 residents sampled. The findings include: Review of the facility policy Oxygen Administration, revised 7/2013, revealed .Verify that there is a physician's order .Review the physician's orders .for oxygen administration . Medical record review revealed Resident #69 was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, Asthma, Atrial Fibrillation, Sleep Apnea, and Muscle Weakness. Medical record review of an Order Summary Report, dated 9/20/19, revealed .Oxygen: RUN @ [at] (2) L/MIN [liters per minute] VIA .N/C [nasal cannula] .CONTINUOUS . Medical record review of Resident #69's 5 day Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating the resident had severe cognitive impairment.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-10-08 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview the facility failed to provide evaluation and rationale for continued use of an as needed (PRN) antianxiety drug beyond 14 days for 1 Resident (#19) of 5 residents reviewed for unnecessary medications. The findings include: Medical record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, Major Depressive Disorder, Insomnia, and Anxiety. Medical record review of an Order Summary Report dated 10/8/19 revealed .Ativan [an anti-anxiety drug] 0.5 mg [milligram] .every 12 hours as needed for agitation .Order Date .04/20/2019 .Start Date .4/21/2019 .End Date .04/21/2020 . Medical record review of a Medication Administration Record dated 10/1/19 - 10/31/19 revealed Ativan 0.5 mg was administered to Resident #19 on 10/1/19 and 10/3/19. Medical record review of the physician's notes, pharmacy recommendations, and psychiatric notes revealed no documented rationale for the continued use of Ativan PRN antianxiety beyond the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-10-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observation, and interview, the facility failed to ensure staff disinfected the hands after medication administration for 1 of 3 nurses observed during medication administration. The findings include: Review of the facility policy, revised date 2/2018, revealed .5. Employees must wash their hands .using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents . Observation on 10/6/19 at 10:15 AM, in the 200 hallway, of medication administration with Licensed Practical Nurse (LPN) #1 revealed after administering the medications to a resident, the LPN returned to the medication cart, opened the cart and retrieved medication without disinfecting the hands. Interview with LPN #1 on 10/6/19, at 10:35 AM, in the hallway, confirmed she had not disinfected her hands after administering the medication and prior to retrieving medication from the cart. Interview with the Director of Nursing (DON) on 10/8/19 7:34 AM, in the DON's office, confirmed staff are to disinfect hands after each…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$15,041 in federal fines across 1 penalty.
- $15,041 — penalty dated 2024-07-31
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to PRESTIGE ADMINISTRATIVE SERVICES — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.6 | -1.6 vs chain |
| Health inspection | 1 of 5 | 2.4 | -1.4 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 2 of 5 | 3.2 | -1.2 vs chain |
The other 8 homes this chain runs (chain average 2.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| B&Y HEALTHCARE S CORP | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 12/31/2019 |
| CODY HEALTHCARE S CORP | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 12/31/2019 |
| B&Y TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% | since 12/31/2019 |
| CRAIG FLASHNER 2007 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% | since 12/31/2019 |
| NORCROSS, ROBERT | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 02/01/2007 |
| ROGERS, STACEY | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 10/30/2014 |
| KIRK, KRISTINE | Individual | W-2 MANAGING EMPLOYEE | — | since 07/18/2011 |
| FLASHNER, CRAIG | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 12/31/2019 |
| NORTHPOINT REGIONAL LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2007 |
| PRESTIGE ADMINISTRATIVE SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2016 |
| PERLSTEIN, YITZCHOK | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/31/2019 |
CMS files one row per role, so the 12 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $719K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Tennessee Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 445242. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
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