Life Care Center Of Red Bank
1020 Runyan Dr, Chattanooga, TN 37405 · For profit - Corporation · 148 certified beds · (423) 877-1155 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 Oct 2021
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- inspectors recorded 3 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,512 in federal fines (most recent 2024-02-29)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (61%) runs well above the national median (45%)
- about 18% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 fell from 2 to 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 | 16.0% | 14.0% | 15.4% | typical |
| Long-stay residents who lose too much weight | 4.1% | 6.1% | 5.4% | better |
| 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 | 0.4% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.4% | 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 | 1.8% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 28.4% | 17.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 35.3% | 31.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 91.5% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.5% | 5.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 31.7% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.6% | 16.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 1.7% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 94.5% | 79.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.3% | 22.6% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.7% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.35 | 1.67 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.56 | 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.
51.3% 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 123 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 79.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 38 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.44 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 51.3%CMS range 42.5–60.4 | 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 | 10.2%CMS range 6.9–14.3 | 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 | 79.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 68.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 71.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.8% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 23.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 3.2% | 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 | 8.5%CMS range 5.1–12.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.15 | 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 148 beds and averages 83.9 residents a day — about 57% occupied, or roughly 64 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 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 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 2.95 hrs/resident/day on weekends vs 3.84 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.62 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 61% is well above the national median of 45%.
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
24 citations, most serious first. The 15 most serious are shown; the remaining 9 are one tap away and print in full.
- Actual harm · G2024-02-29 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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, facility procedure review, medical record review, facility investigation review, and interviews the facility failed to implement the comprehensive care plan for 1 resident (Resident #3) which resulted in actual Harm, of 5 residents reviewed for care plans for accidents. The facility was cited as past non-compliance and the facility is not required to submit a Plan of Correction for F-656. Non-compliance began on 9/26/2022 and ended on 8/28/2023. The findings include: Review of the facility's policy titled, Comprehensive Care Plans and Revisions, dated 3/2/2022, showed .Procedure .The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery .Additional interventions on existing problems . Review of a facility procedure titled, Transfer with a Mechanical Lift…
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.
- Actual harm · Gcited before2024-02-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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, facility procedure review, medical record review, review of facility investigation documentation, and interviews the facility failed to prevent falls with major injury for 1 resident (Resident #3) of 5 residents reviewed for accidents. The facility was cited as past non-compliance and the facility is not required to submit a Plan of Correction for F-689. Non-compliance began on 9/26/2022 and ended on 8/28/2023. The findings include: Review of the facility's policy titled, Fall Management, dated 4/7/2022, showed .Accident .Refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident .Avoidable Accident .an accident occurred because the facility failed to .Evaluate/analyze the hazards and risks and eliminate them, if possible .if not possible .identify and implement measures to reduce the hazards/risks as much as possible .Implement interventions, including adequate supervision and assistive devices, consistent with a resident's…
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.
- Actual harm · G2024-02-29 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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, review of facility documentation, and interview, the facility's Administration failed to provide effective oversight and follow the facility's corporate notification protocol for falls with major injury which resulted in actual Harm of Resident #3 of 5 residents reviewed for falls and had the potential to affect all 86 residents residing in the facility. The facility was cited as past non-compliance and the facility is not required to submit a Plan of Correction for F-835. Non-compliance began on 9/26/2022 and ended on 8/28/2023. The findings include: Review of the facility's policy titled, Incident and Reportable Event Management, dated 9/14/2023, .each resident receives adequate supervision .to prevent accidents .facility has identified the following events as being Never Event [fall that results in serious injury or fracture] and when these type of events occur the Director or Nursing and/or Executive Director should contact their Regional and Divisional team to review 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.
- Actual harm · G2019-07-31 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 follow professional standards of practice per the comprehensive care plan for pain management for 1 resident (#87) of 3 residents reviewed for pain management of 21 sampled residents. The facility's failure to follow professional standards of practice for pain management resulted in actual HARM to Resident #87. The findings include: Review of the facility policy Pain Management dated 11/2016 revealed, .Purpose .To promote patient well-being by reducing their pain .Based on comprehensive assessment [of] the patient, the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences . Medical record review revealed Resident #87 was admitted to the facility on [DATE] with diagnoses including Acquired Absence of Right Leg Below Knee, End Stage…
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.
- Actual harm · G2019-07-31 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 provide effective pain management for 1 resident (#87) of 3 residents reviewed for pain of 21 sampled residents. The facility's failure to implement an effective pain management program for Resident #87 resulted in an increase in severe pain and actual HARM to Resident #87. The findings include: Review of the facility policy, Pain Management, dated 11/2016, revealed, .Purpose .To promote patient well-being by reducing their pain .Based on .assessment .the facility must ensure that pain management is provided to residents who require such services .Recognition and Management of Pain: In order to help a patient attain or maintain his or her highest practicable level of well-being and to prevent or manage pain, the facility .Recognizes when the patient is experiencing pain .Evaluates the existing pain .Manages or prevents pain . Medical record review revealed Resident #87 was admitted to the facility on [DATE]…
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 · Fcited before2024-07-17 · 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, observation, and interview the facility failed to ensure food items were stored properly in the kitchen and in 2 of 2 nourishment rooms and failed to ensure dishes and food preparation equipment were clean and sanitary which had the potential to affect 84 of 85 residents. The findings include: Review of the facility's policy titled, Sanitation and Food Safety, revised 9/8/2022, revealed .food is placed in a .sanitary .container .is labeled .with date .Associate food will not be stored with resident food .Opened packages of food are resealed tightly to prevent contamination of the food item . Review of the facility's policy titled, Safe Food Handling, revised 4/26/2023, revealed .All working surfaces, utensils and equipment are cleaned and sanitized appropriately after each use .Perishable food is not left in the danger zone [41 degrees to 135 degrees Fahrenheit] more than four hours .If this occurs, it is to be discarded . Review of the facility's policy titled, Sanitation and Maintenance, revised 4/26/2023, revealed .Director of Food and Nutrition…
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 · F2024-07-17 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 policy review, medical record review, observations, and interviews the facility failed to implement Enhanced Barrier Precautions (EBP) for 8 residents (Residents #34, #1,#43,#50,#21,#72,#66, and #587) of 85 residents reviewed for invasive devices. The findings include: Review of the facility's policy titled, Enhanced Barrier Precautions, dated 6/3/2024, revealed .The facility should use Enhanced Barrier Precautions (EBP) as an additional .mitigation strategy for residents that meet the following criteria, during high-contact resident care activities .indwelling devices .examples include central lines, urinary catheters, feeding tubes . Review of the medical record revealed Resident #34 was admitted to facility on 10/6/2023 with diagnoses including Acute on Chronic Systolic Congestive Heart Failure, Stage 3 Chronic Kidney Disease, and Neuromuscular Dysfunction of Bladder. Review of a comprehensive care plan initiated on 10/6/2023 and revised on 5/6/2024, revealed .resident has Indwelling…
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 · D2024-07-17 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 medical information was not visible for 1 resident (Resident #52) of 85 residents observed. The findings include: Review of the facility policy titled, Resident Rights, reviewed on 9/25/2023, revealed .A facility must treat each resident with respect and dignity .The resident has a right to personal privacy and confidentiality of his or her personal and medical records . Review of the facility policy titled, Dignity, reviewed on 9/25/2023, revealed .Each resident has the right to be treated with dignity and respect .The resident has a right to a dignified existence .The facility must protect and promote the rights of the resident .The resident has a right to be treated with respect and dignity .Staff should not .document in charts/electronic health records where others can see a resident's information . Review of the medical record review revealed Resident #52 was admitted to the facility on [DATE]…
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 · D2024-07-17 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 notify resident representatives of a change in condition for 2 residents (Residents #14 and #46) of 6 residents reviewed. The findings include: Review of the facility policy titled, Changes in Resident's Condition or Status, reviewed on 8/9/2023, revealed .This facility will notify the .resident/resident representative of changes in the resident's condition or status .A facility must immediately .notify .the resident representative(s) when there is .An accident involving the resident which results in injury and has the potential for requiring physician intervention . Review of the facility policy titled, Incident and Reportable Event Management, reviewed on 9/14/2023, revealed .Event Management includes .Fall .Unwitnessed or Witnessed .Incident/Injury .The licensed nurse should create an 'event note' and include .Notification of family or responsible party . Review of the medical record revealed Resident #14 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.
- Potential for harm · D2024-07-17 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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, review of the Resident Assessment Instrument (RAI) Manual 3.0, medical record review, and interview the facility failed to accurately complete Minimum Data Set (MDS) assessments for 4 residents (Resident #1, #84, #45 and #52) of 42 residents reviewed for accuracy of MDS assessments. The findings include: Review of the facility's policy titled, Certification of Accuracy of the MDS, dated 8/17/2022, revealed .Each person completing .the MDS is required to sign the attestation statement certifying they have used the .Resident Assessment Instrument User's Manual to complete the MDS .The assessment must accurately reflect the resident's status . Review of the RAI Manual 3.0 dated 10/2023, revealed .The MDS is completed on all residents in Medicare or Medicaid certified facilities .Sections A-Q contain the clinical data items used to assess residents in the nursing facility .Assure that the information found in the resident's most current assessment .report changes in the resident's…
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 before2024-07-17 · 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 resubmit a Pre-admission Screening and Resident Review (PASARR) timely after a new mental health diagnosis for 2 residents (Residents #11 and #39) of 10 residents reviewed for PASARR. The findings include: Review of the facility policy titled, Pre-admission Screening and Resident Review (PASARR), reviewed on 9/25/2023, revealed .The facility will ensure that all potential admissions are to be screened for possible serious mental disorders .This initial pre-screening is referred to as PASARR Level I, and is completed prior to admission .A negative Level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder .arises later .A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program .Coordinate includes .Referring all Level II residents and all residents with newly evident or possible serious mental disorder .for level II…
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 · D2024-07-17 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 change a tube feeding bag and tubing every 24 hours for 1 resident (Resident #587) of 2 residents reviewed for tube feeding. The findings include: Review of the facility policy titled, Enteral Nutrition Therapy, revised 5/28/2024, revealed .The facility will provide intermittent enteral nutrition therapy in accordance with physician orders and professional standards of practice .Enteral feeding .also referred to as 'tube feeding' .delivery of nutrients .directly into the stomach . Review of the medical record revealed Resident #587 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Gastrostomy [surgical procedure to make an opening in the stomach for tube feeding], Cognitive Communication Deficit, and Chronic Obstructive Pulmonary Disease (COPD). Review of a Nutrition assessment for Resident #587 dated 7/15/2024, revealed the resident was to receive nutritional…
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 · D2024-07-17 · 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 store the nebulizer and the Continuous Positive Airway Pressure (CPAP - equipment used for individuals with sleep apnea) masks appropriately for 3 residents (Residents #587, #588, and #589) of 21 residents reviewed for respiratory equipment. The findings include: Review of the facility policy titled, Oxygen Administration (Safety, Storage, Maintenance), revised 2/27/2024, revealed .facility must ensure that a resident who needs respiratory care .is provided such care, consistent with professional standards of practice .Store .respiratory supplies in bag labeled with resident's name when not in use . Review of the medical record revealed Resident #587 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Obstructive Sleep Apnea and Chronic Obstructive Pulmonary Disease (COPD). Review of a mental status assessment dated [DATE], revealed Resident #587 scored a 5 on 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 · D2024-07-17 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on facility policy review, observation, and interview, the facility failed to ensure 1 of 1 garbage and refuse storage area was kept in a sanitary condition. The findings include: Review of the facility's policy titled, Disposal of Garbage and Refuse, reviewed 4/30/2024, revealed .All areas where garbage/refuse is located is kept clean, free of debris .The garbage storage area is maintained in a sanitary condition to prevent the harborage and feeding of pests . During an observation on 7/15/2024 at 11:44 AM, with the Certified Dietary Manager (CDM), the dumpster area had 2 dumpsters surrounded on 3 sides by a fence. Between the fence and the right dumpster, there was trash on the ground consisting of paper, used exam gloves and straws. Behind the dumpster there was 1 partially decayed animal carcass with exposed bones. During an interview on 7/15/2024 at 11:50 AM, the CDM confirmed the dumpster area was generally unclean and had not been maintained in a sanitary condition.
- Potential for harm · D2024-02-29 · 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 facility policy review, medical record review, and interviews, the facility failed to maintain an accurate medical record for 1 resident (Resident #3) of 15 residents reviewed for medical records. The findings include: Review of the facility's policy titled, Authentication of All Record Entries, dated 3/10/2023, .entries are made as soon as possible after an event or observation is made . Review of the facility's policy titled, Refusal of Care or Treatment, dated 8/10/2023, .Documentation of the refusal .should be present in the resident's medical record . Resident #3 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Hemiparesis, Lack of Coordination, and Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #3 scored 13 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact and required total 2-person assistance with transfers. Review of Resident # 3's comprehensive care…
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 9 citations
- Potential for harm · Fcited before2021-10-20 · 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, observation, and interview, the facility failed to date and label foods available for resident use and failed to discard molded food available for resident use in 1 of 1 kitchen, which had the potential to affect 80 of 85 residents. The findings include: Review of the facility's policy titled, Food Safety, dated 11/28/2017, showed Food is stored and maintained in a clean, safe and sanitary manner .to minimize contamination and bacterial growth .Food not safe for consumption or the safety of the food is in question will be removed from storage . Review of the facility's policy titled, 'Use by Date' Guide, dated 03/18/2020, showed The following guide can be used to determine a 'use by date' when labeling opened or unopened food that must be used within a certain time frame. Please note that this information is used when there are no guidelines on the containers of food . Further review showed frozen and thawed bread should be labeled with a Use By date of .7 days, after thawed for quality purposes . Observation of the kitchen with the Dietary Director 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 · D2021-10-20 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 medications were administered according to professional standards as well as the facility policy for 2 residents (Resident #52 and Resident #54) of 6 residents reviewed for medication administration. The findings include: Review of the facility policy, Respiratory Medication Administration, revised 10/14/2021 showed .Policy .will provide Respiratory Medication Administration in accordance with professional standards of practice .This facility will utilize .following .Lippincott procedures .Nebulizer [inhaled breathing treatment] Therapy, Small Volume Procedure .Remain with the patient and continue the treatment until the nebulizer begins to sputter . Resident #52 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Uterus, Anxiety, Constipation, Partial Intestinal Obstruction, Osteoporosis, Muscle Weakness, and Difficulty in Walking, Review of the Physician's Order…
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 · D2021-10-20 · 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, facility investigation review, and interview, the facility failed to protect 1 resident (Resident #20) from abuse of 15 residents reviewed for abuse. The findings include: Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, revised 8/10/2021, showed .nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse .Each resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone. This includes .other residents .It is the policy and practice of this facility that all residents will be protected from all types of abuse .Training .Understanding behavioral symptoms of residents that may increase the risk of abuse .These symptoms include .Wandering or elopement-type behaviors . Medical record review showed Resident #20 was admitted to the facility on [DATE] with diagnoses including Paraplegia, Chronic Pain,…
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 · D2021-10-20 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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, facility investigation review, and interview, the facility failed to report an allegation of abuse to the State Survey Agency for 1 resident (Resident #20) of 15 residents reviewed for abuse. The findings include: Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, revised 8/10/2021, showed .Ensure all alleged violations involving abuse .are reported immediately, but not later than 2 hours after the allegation is made .to the State Survey Agency . Medical record review showed Resident #20 was admitted to the facility on [DATE] with diagnoses including Paraplegia, Chronic Pain, and Rheumatoid Arthritis. Review of Resident #20's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Medical record review showed Resident #26 was admitted to the facility on [DATE] with 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 · D2021-10-20 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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, facility investigation review, and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 resident (Resident #20) of 15 residents reviewed for abuse. The findings include: Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, revised 8/10/2021, showed .It is the policy of this facility that reports of abuse .are promptly and thoroughly investigated .The written summary of the investigation should include .An interview with the person(s) reporting the incident .Interviews with any witnesses to the incident .The name(s) of any witnesses to the incident . Medical record review showed Resident #20 was admitted to the facility on [DATE] with diagnoses including Paraplegia, Chronic Pain, and Rheumatoid Arthritis. Review of Resident #20's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15, indicating…
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 before2021-10-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 medications were stored and administered safely for 1 resident (Resident #51) of 4 residents reviewed for medication administration when a nurse left the resident's medication at the bedside unattended. The findings include: Review of the facility policy, Oral drug Administration, dated 5/21/2021 revealed .Stay with the patient until the patient has swallowed the drug. If the patient seems confused or disoriented, check the mouth to make sure that the patient has swallowed the drug . Resident #51 was admitted to the facility on [DATE] with diagnoses including Dysphagia, Severe Protein-Calorie Malnutrition, and Cerebrovascular Accident. Review of Resident #51's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 9, indicating the resident had moderately impaired cognition. Further review revealed Resident #51 required supervision for eating…
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 · D2021-10-20 · 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 facility policy review, medical record review, and interview, the facility failed to ensure a Gradual Dose Reduction (GDR) was attempted for a psychotropic (a medication that affects behavior, mood, thoughts, or perception) medication and failed to reassess and renew a physician's order for an as needed (PRN) anti-anxiety medication timely for 1 resident (Resident #49) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility's policy titled, Psychotropic Medication Use, dated 12/1/2007, showed .A psychotropic drug is any medication that affects brain activities associated with mental processes and behavior .Facility should comply with the Psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services ('CMS'), the State Operations Manual, and all other Applicable Law relating to the use of psychopharmacologic medications including gradual dose reductions .PRN orders for psychotropic drugs should be limited to 14 days. If 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 before2019-07-31 · 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 PASARR after newly identified serious mental disorders were diagnosed for 2 residents (#27, #44) of 6 residents reviewed for PASARR of 21 sampled residents. The findings include: Medical record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including Psychosis, Mood Disorder, and Delusional Disorder. Continued review revealed diagnosis of Schizophrenia was added on 3/18/16, Major Depressive Disorder was added on 12/29/16, and a diagnosis of Bipolar II Disorder was added on 2/13/19. Medical record review of the most recent PASARR Level I assessment dated [DATE] revealed Resident #27 had no diagnosis of mental illness. Interview with the Director of Nursing (DON) on 7/30/19 at 8:30 AM, in the conference room, confirmed Resident #27 was not referred to the state-designated authority for a PASARR Level 2 screen after the resident was newly diagnosed…
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 before2019-07-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 ensure adequate supervision for 1 resident (#26) of 3 residents reviewed for falls of 21 sampled residents. The findings include: Review of the facility policy Fall Management with effective date 12/13/18 revealed, .The facility must ensure .each resident receives adequate supervision .to prevent accidents . Medical record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Muscle Weakness, Repeated Falls, and Altered Mental Status. Medical record review of the resident Care Plan dated 3/2/19 revealed, .At risk for injury from falls Relating to .impaired mobility .weakness .Cognitive deficits .frequent falls . Medical record review of a 30 day Minimum Data Set (MDS) dated [DATE] revealed the resident scored a 3 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. Continued review revealed…
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
$8,512 in federal fines across 1 penalty.
- $8,512 — penalty dated 2024-02-29
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 LIFE CARE CENTERS OF AMERICA — 194 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 | 2 of 5 | 3.4 | -1.4 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 2 of 5 | 3.3 | -1.3 vs chain |
| Quality measures | 3 of 5 | 4.5 | -1.5 vs chain |
The other 193 homes this chain runs (chain average 3.4★, per CMS)
Showing 40 of 193; lowest-rated first.
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 | Since |
|---|---|---|---|
| BROOM, SHERRY | Individual | W-2 MANAGING EMPLOYEE | since 03/23/2015 |
| CROSS, CINDY | Individual | CORPORATE OFFICER | since 08/24/2015 |
| THURMOND, JOAN | Individual | CORPORATE OFFICER | since 08/24/2015 |
| LIFE CARE CENTERS OF AMERICA, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2017 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner 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.
This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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 445240. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-17, 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 →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.