The Health Center At Standifer Place
2626 Walker Rd, Chattanooga, TN 37421 · For profit - Limited Liability company · 444 certified beds · (423) 490-1599 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has a citation for mishandling residents’ money or property (F0569)
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
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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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 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 improved from 4 to 5 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 | 10.6% | 14.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.8% | 6.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.6% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.4% | 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 | 2.3% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 9.3% | 17.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 30.0% | 31.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 99.7% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.0% | 5.0% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 13.7% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.7% | 16.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.7% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 94.1% | 79.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.0% | 22.6% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.1% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.47 | 1.67 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.99 | 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.
54.4% 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 141 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 49.4% 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 83 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% 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 | 54.4%CMS range 44.1–62.8 | 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 | 10.8%CMS range 8.1–14.2 | 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 | 49.4% | 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 | 57.8% | 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 | 43.4% | 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 | 99.1% | 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 | 100.0% | 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 | 0.0% | 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 | 6.9%CMS range 4.1–10.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.19 | 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 444 beds and averages 382.2 residents a day — about 86% occupied, or roughly 62 beds typically open. It runs fairly full. 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 3.83 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.18 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 3.27 hrs/resident/day on weekends vs 4.06 on weekdays — 19% thinner on weekends. RN hours go from 0.52 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% is about the same as 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.
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.
15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.
- Potential for harm · D2025-07-23 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 revise the care plan for 1 resident (Resident #142) of 42 residents reviewed for care plans. The findings include:Review of the facility's policy titled, Care Plan Policy, dated 12/2023, revealed .comprehensive care plan .includes .services that are to be furnished .maintain the resident's highest practicable .well-being .individualized interventions .care plans are updated as needed .Review of the facility's policy titled, Side Rail Assessment, dated 11/2018, revealed .side rail(s) are used to assist with resident safety, positioning .update care plan as needed .Review of the medical record revealed Resident #142 was admitted to the facility on [DATE] with diagnoses including Dysphagia, Hypertension, and Moderate Protein-Calorie Malnutrition.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #142 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment…
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 · D2025-07-23 · 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 Respiratory Therapy Manual review, medical record review, observation, and interview, the facility failed to properly date and store a nasal cannula for 1 resident (Resident #220) of 7 residents reviewed for oxygen therapy and failed to properly date an inline suction catheter (closed suction system designed to remove secretions in patients with artificial airways) for 1 resident (Resident #147) of 11 residents sampled with inline suction catheters.The findings include: Review of the facility's undated Respiratory Therapy Manual revealed .Change Out of Respiratory Disposables.applies to OXYGEN .VENTILATORS.SUCTION.Nasal Cannulas.Inline suction catheters.are to be changed weekly. Medical record review revealed Resident #147 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure, Tracheostomy Status (surgically created opening into the windpipe to provide an alternative airway for…
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 · D2025-07-23 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
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 garbage and refuse were properly contained in 1 of 3 dumpsters (dumpster B) and failed to ensure the outside dumpster area was maintained in a sanitary and orderly condition. The findings include:Review of the facility's policy titled, Garbage/Refuse Disposal, dated 5/2023, revealed .All garbage, refuse .shall be disposed of in a sanitary manner .The area around dumpsters shall be free of waste products, including paper trash .but not limited to .gloves .to prevent harborage and feeding of pests .During an observation of the outside dumpster area on 7/22/2025 at 10:43 AM, with the Dietary Manager, revealed 3 dumpsters for waste disposal. Observation of the ground surrounding the dumpster area revealed cardboard, multiple gloves, and multiple plastic eating utensils. Further observation revealed 1 dumpster (dumpster B) had no drain plug intact resulting in the dumpster contents being left open to the elements and potential to attract pests.During an interview on 7/22/2025 at 10:45 AM, 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 before2025-07-23 · 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 policy review, medical record review, observation, and interview the facility failed to ensure biohazard waste was contained properly for 1 resident (Resident #3) of 6 residents observed on transmission based precautions, failed to ensure a sanitary environment for 1 resident (Resident #95) of 4 residents observed, and failed to offer hand hygiene assistance prior to meals to 5 residents (Residents #244, #199, #268, #359, and #350) on 1 of 4 hallways observed for meal tray distribution.The findings include:Review of the facility's policy titled, Handwashing and Hand Hygiene, dated 10/2024 revealed .staff will encourage residents to complete hand hygiene .before eating .Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Tracheostomy (surgical opening the trachea that provides airway for breathing) and Multi-Drug-Resistant Organisms (MDRO) and was in Contact Precautions and Droplet Precautions.During an observation on 7/21/2025 at 3:08 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 · D2025-07-23 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure 2 of 2 Physical Therapy Gym's mat platform tables were maintained in good repair. The findings include:During an observation on 7/23/2025 at 11:20 AM, in the facility's Physical Therapy Gym, revealed 2 mat platform tables had multiple large rips and tears which exposed the foam padding.During an interview on 7/23/2025 at 11:25 AM, the facility's Director of Therapy, confirmed, .the rips and tears have been there a while and I see what you are saying, they could be a problem, and we do need them covered or replaced .
- Potential for harm · D2022-06-09 · 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 PASRR (Preadmission Screening and Resident Review) Level II evaluation for 1 resident (Resident #193) of 6 residents reviewed for PASRR Level II evaluation. The findings include: Review of the facility policy PASRR Policy, undated, showed .Individuals who have or are suspected to have MI [Mental Illness] or ID/DD [Intellectual Disability/Mental Retardation] or related conditions have a level II PASRR review .when individuals with MI or ID/DD have a significant change in physical or mental condition, a new level II PASRR completed .all new orders .are reviewed no less frequently than weekly .an updated PASRR will be completed and submitted .to determine if the resident requires specialized services . Resident #193 was admitted to the facility on [DATE] with diagnoses including Depression, Anxiety, Type 2 Diabetes, Chronic Kidney Disease, and Hypertension. A diagnosis of Dementia with Behavioral Disturbances 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 · D2022-06-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 the medical record review and interviews the facility failed to provide restorative nursing care for 1 resident (Resident #91) of 10 residents reviewed. The findings include: Resident #91 was admitted to the facility on [DATE] with diagnoses including Surgical Aftercare Following Surgery, Open Wound of Lower Back and Pelvis, Muscle Weakness, Difficulty Walking, Adult Failure to Thrive, Pressure Ulcer, Stage 4, and Major Depressive Disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #91 had moderate cognitive impairment. He required extensive assistance of 2 staff persons with bed mobility, extensive assistance of 1 staff person with dressing, toileting, and personal hygiene. The resident required set up assistance with meals and could eat independently. Resident #91 received 170 minutes of occupational therapy services and 134 minutes of physical therapy services. Review of the Physician Order dated 4/11/2022 showed .Restorative ROM .B LE as tolerated .…
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 · D2022-06-09 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 interviews, the facility failed to address the Pharmacist's recommendations for 1 resident (Resident #114) of 5 residents reviewed for unnecessary medications. The findings include: Resident #114 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Vascular Dementia, Anxiety Disorder, Major Depressive Disorder, Encounter for Palliative Care (Hospice), and Unspecified Dementia without Behavioral Disturbance. Review of the Clinical Pharmacist Review dated 3/10/2022 showed .Haloperidol [a medication to treat mental disorders] .Seroquel [a medication to treat mental disorders] XR [extended release] 50 mg [milligrams] .Valium [an anxiety medication] 5 mg .Please review for possible trial gradual dose reduction if patient is ineligible, document reason . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #114 had moderate impaired cognition. Review of the 7 day look back showed the resident received antipsychotic…
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 before2022-06-09 · 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 policy review, medical record review, observation, and interview the facility failed to ensure infection control practices were followed for 1 resident (Resident #540) of 4 residents reviewed for transmission-based precautions which had the potential to result in transmission of COVID-19 (an infectious disease caused by the SARS-CoV-2 virus). The findings include: Review of the facility's undated policy titled, INFECTION PREVENTION AND CONTROL PROGRAM/PLAN, showed .will maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .Transmission-based Precautions are used additionally with Standard Precautions when caring for those residents who are known or suspected to be infected or colonized with pathogens that can be transmitted by contact or by droplets .A medical staff order is needed for the application and removal of transmission-based…
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 · D2019-07-31 · 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 medical record review, and interview, the facility failed to refer 1 resident (#90) identified with a possible serious mental disorder to the state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) of 6 residents reviewed for PASARR of 37 sampled residents. The findings include: Medical record review revealed Resident #90 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, End Stage Renal Disease, and Post-Traumatic Stress Disorder. Medical record review of a PASARR Level I assessment dated [DATE] revealed the resident had no diagnosis of mental illness. Medical record review of a Psychiatric Evaluation dated 3/11/19 revealed .Worsening depression .she reports the increase of Wellbutrin [medication to treat depression] did not help .she does admit to a history of mood swings and thinks she may have bipolar [a psychiatric disorder] .Diagnosis .Bipolar 1 Disorder . Interview with the Minimum Data Set (MDS) Coordinator on 7/30/19 at 1:39…
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 5 citations
- Potential for harm · D2019-07-31 · 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 medical record review and interview, the facility failed to implement a comprehensive care plan for pain management for 1 resident (#266) of 3 residents reviewed for pain of 37 residents sampled. The findings include: Medical record review revealed Resident #266 was admitted to the facility on [DATE] with diagnoses including Osteoarthritis, Intervertebral Disc Degeneration Lumbar Region, Spinal Stenosis Lumbar Region, Chronic Pain Syndrome, Fibromyalgia, Hemiplegia, and Muscle Weakness. Medical record review of the comprehensive care plan dated 4/2/19 revealed . risk for alteration of her comfort d/t [due to] decreased mobility, and dx [diagnosis] of OA [osteoarthritis, a type of arthritis that occurs when the flexible tissues at the ends of the bones wear down], Chronic pain syndrome and Fibromyalgia [widespread muscle pain and tenderness] . administer medications as ordered . Medical record review of a Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS)…
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 · D2019-07-31 · 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 and interview, the facility failed to ensure pain medication was administered timely resulting in an increase in pain for 1 resident (#266) of 3 residents reviewed for pain of 37 sampled residents. The findings include: Review of the facility policy Medication Administration dated 6/2018 revealed, .Medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in the medical management of diagnoses .Assure the medication is administered .at the right time . Medical record review revealed Resident #266 was admitted to the facility on [DATE] with diagnoses including Osteoarthritis, Intervertebral Disc Degeneration Lumbar Region, Spinal Stenosis Lumbar Region, Chronic Pain Syndrome, Fibromyalgia, Hemiplegia, and Muscle Weakness. Medical record review of the comprehensive care plan dated 4/2/19 revealed, . risk for alteration of her comfort d/t [due to] decreased mobility, and dx [diagnosis] of…
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 · D2019-07-31 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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, review of the facility's Assignment Sheets, review of the facility's Midnight Census Reports, resident interviews, and staff interviews, the facility failed to maintain adequate staffing levels to ensure timely administration of medications for 1 resident (#266) residing on 1 unit (2 East) of 10 units observed. The findings include: Medical record review revealed Resident #266 was admitted to the facility on [DATE] with diagnoses including Osteoarthritis, Intervertebral Disc Degeneration Lumbar Region, Spinal Stenosis Lumbar Region, Chronic Pain Syndrome, Fibromyalgia, Hemiplegia, Old Myocardial Infarction, Essential Hypertension, Atherosclerotic Heart Disease, Supraventricular Tachycardia, Unspecified Atrial Flutter, History of Transient Ischemic Attack, Presence of a Cardiac Pacemaker, and Muscle Weakness. Medical record review of the comprehensive care plan dated 4/2/19 revealed . risk for alteration of her comfort d/t [due to] decreased mobility, and dx [diagnosis] of OA…
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 · D2019-07-31 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 1 resident (#266) was free from significant medication errors of 7 residents reviewed for medication administration of 37 residents sampled. The findings include: Review of the facility policy Medication Administration dated 6/2018 revealed .Medications are administered safely and appropriately to aid resident to overcome illness, relieve and prevent symptoms, and help in the medical management of diagnoses .Assure the medication is administered .at the right time . Medical record review revealed Resident #266 was admitted to the facility on [DATE] with diagnoses including Osteoarthritis, Intervertebral Disc Degeneration Lumbar Region, Spinal Stenosis Lumbar Region, Chronic Pain Syndrome, Fibromyalgia, Hemiplegia, Old Myocardial Infarction, Essential Hypertension, Atherosclerotic Heart Disease, Supraventricular Tachycardia, Unspecified Atrial Flutter, History of Transient Ischemic Attack, Presence of a Cardiac…
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.
- No harm found · C2019-07-31 · tag F0569 — widespreadNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
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 the facility policy, medical record review, review of the facility's documentation of the Notification Summary Report (resident trust funds/Resident Statement), and interview, the facility failed to refund the balance of a Patient Trust Fund, within the required time frame, for 2 discharged residents (#402 and #403) of 313 Patient Trust Funds reviewed. The findings include: Review of the facility policy, Patient Trust, Subject: Refunds, revised date 10/10, revealed .Timing (Schedule) the funds should be refunded within 30 days of death or discharge . Medical record review revealed Resident #402 was admitted to the facility on [DATE]. Continued review revealed the Resident was discharged to the hospital on [DATE]. Review of the Resident Statement (trust fund) revealed the Resident expired on [DATE]. Continued review revealed Resident #402 had a balance of $1719.70. Medical record review revealed Resident #403 was admitted to the facility on [DATE]. Continued review revealed Resident #403 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.
“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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| COVENANT HEALTH SERVICES LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 10/01/2013 |
| STRAWN, JOHN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 10/01/2013 |
| BOOZER, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2015 |
| BREAKEY, ANGELA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2015 |
| PENDLEY, BRUCE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/07/2009 |
| HEALTH, EDUCATIONAL, AND HOUSING FACILITY BOARD OF THE CITY OF CHATTAN | Organization | ADP OF THE SNF | — | since 01/14/2000 |
| RIVERCITY STAFFING, LLC | Organization | ADP OF THE SNF | — | since 10/01/2013 |
| STANDIFER PLACE PROPERTIES LLC | Organization | ADP OF THE SNF | — | since 11/07/2025 |
| TENNESSEE HEALTHCARE ADVISORS, LLC | Organization | ADP OF THE SNF | — | since 11/01/2007 |
CMS files one row per role, so the 14 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
5 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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 445111. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-23, 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.