Church Hill Post-Acute And Rehabilitation Center

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

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.

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.

56.6% 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 56 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 35.0% 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 20 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 0.27 therapist hours per resident per day in 2026Q1 — more than 39% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% 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.

Staffing

How full it usually is: this home is certified for 124 beds and averages 89.6 residents a day — about 72% occupied, or roughly 34 beds typically open. It usually has some room. 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 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 3.09 hrs/resident/day on weekends vs 3.69 on weekdays — 16% thinner on weekends. RN hours go from 0.40 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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 fewer than at the previous inspection — improving. 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.

35 citations, most serious first. The 22 most serious are shown; the remaining 13 are one tap away and print in full.

• Immediate jeopardy · L2024-11-18 · tag F0726 — failed to have competent, trained nursing staff — widespread
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  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, job description reviews, review of the Centers for Disease (CDC) website for recommendations and guidance for Enhanced Barrier Precautions (EBP) and Coronavirus Disease 2019 (COVID-19), medical record reviews, observations, and interviews, the facility failed to ensure the nursing staff were knowledgeable and fully understood of 6 residents (Residents # 13, #24, #25, #52, #56, and #83) in EBP on 3 of 4 hallways (200, 300, and 400 hallways), of 4 residents (Residents #102, #507, #508, and #509) with active COVID-19 infection on 1 of 4 hallways (100 hallway), and implemented the appropriate use of Personal Protective Equipment (PPE) for isolation rooms to prevent and control the spread of COVID-19, and other infectious organisms. The facility's non-compliance placed the residents in Immediate Jeopardy (IJ) (A situation in which the providers noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · L2024-11-18 · tag F0835 — failed to run the facility competently — widespread
  Administer 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, Centers for Disease Control and Prevention (CDC) recommendations and guidance review, job description review, facility assessment review, and interviews, the facility's Administration failed to ensure current CDC guidelines were utilized to prevent and control the spread of COVID-19 to the residents and employees. The facility's Administration failed to ensure the staff were competent and knowledgeable on Enhanced Barrier Precautions (EBP) and COVID-19 isolation practices which included use of appropriate Personal Protective Equipment (PPE) for potentially contagious residents. The facility's Administration failed to accurately identify residents with an active diagnosis of COVID-19. The facility's Administration failed to ensure the completion of COVID-19 testing of the staff during the COVID-19 outbreaks from 8/2024-11/2024. The facility's Administration failed to ensure COVID-19 positive employees and residents were quarantined for the required isolation time frame recommended…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · L2024-11-18 · tag F0837 — widespread
  Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on facility policy review, review of the Centers for Disease Control and Prevention (CDC) recommendations and guidance, job description review, facility assessment review, and interviews, the Governing Body failed to provide oversight to Administration to ensure current CDC guidelines were utilized to prevent and control the spread of COVID-19 to the residents and employees. The Governing Body failed to provide oversight to Administration to ensure the staff were competent and knowledgeable on Enhanced Barrier Precautions (EBP) and COVID-19 isolation practices which included use of appropriate Personal Protective Equipment (PPE) for potentially contagious residents. The Governing Body failed to provide oversight to Administration to accurately identify residents with an active COVID-19 infection. The Governing Body failed to provide oversight to Administration to ensure COVID-19 testing of the staff was completed per CDC guidelines during the COVID-19 outbreaks from 8/2024-11/2024. The Governing Body failed to provide oversight to Administration to ensure COVID-19 positive…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2024-11-18 · tag F0867 — failed to act on quality-improvement findings — widespread
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on facility policy review, job description review, facility assessment review, Quality Assurance and Performance Improvement (QAPI) Plan review, QAPI Meeting Minutes review, facility documentation review, medical record review, observations, and interviews, the facility's QAPI program failed to ensure an effective, data-driven QAPI program that identified quality deficiencies, implement performance improvement activities to address quality concerns, and perform a root cause analysis related to infection control practices. The facility ' s QAPI committee failed to develop and implement effective processes or initiate action plans for performance improvement when the committee failed to recognize poor infection control practices of the facility and to ensure an effective infection control program to mitigate the spread of disease. The facility ' s QAPI program failed to recognize and provide to the staff the updated Centers for Disease Control Guidelines for the isolation and quarantine time of COVID-19 residents and employees, which allowed COVID-19 positive employees to work…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · L2024-11-18 · tag F0880 — failed to prevent and control infections — widespread
  Provide 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, Centers for Disease Control and Prevention (CDC) recommendations and guidance review, medical record review, observations, and interviews, the facility failed to ensure current CDC guidelines dated 6/24/2024 and 10/28/2024 were followed to prevent and control the spread of COVID-19 to residents and staff, failed to identify and track residents with an active COVID-19 infection, failed to wear appropriate Personal Protective Equipment (PPE) in COVID-19 isolation rooms, and failed to perform facility wide employee testing and recommended quarantine time during the COVID-19 outbreaks. The facility failed to ensure COVID-19 positive residents were quarantined according to CDC guidance when Residents #608, #619, and #509 were admitted with COVID-19. The facility's first COVID-19 outbreak started 8/9/2024 through 10/11/2024, which resulted in 28 residents (Residents #96, #31, #45, #33, #11, #64, #609, #93, #15, #510, #611, #80, #612, #506, #615, #613, #614, #54, #68, #27, #53, #12,…

  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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-11-18 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to ensure services were provided to meet professional standards of quality and acceptable standards of clinical practice by not obtaining vital signs per physician orders for residents with an active COVID-19 infection diagnosis for 36 of 40 residents (Resident #96, #45, #31, #33, #11, #609, #64, #93, #15, #510, #612, #611, #80, #506, #613, #615, #54, #68, #27, #53, #12, #95, #74, #3, #30, #37, #617, #34, #618, #72, #103, #507, #102, #508, #619, and #509) reviewed with active COVID-19 infection and 1 of 8 residents (Resident #99) reviewed for medication administration when nursing staff administered oral medication with a 60 milliliter (ml) syringe to Resident #99 who was at high risk for aspiration. The facility's failure to obtain vital signs per physician orders for residents with an active COVID-19 diagnosis and failure to ensure care was provided within the professional scope of practice for medication administration…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · L2021-07-13 · tag F0600 — failed to protect residents from abuse and neglect — widespread
  Protect 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, observation, and interview, the facility failed to prevent and protect 2 residents (Resident #65 and #45) from abuse of 16 residents reviewed for abuse. The facility's failure to ensure interventions were implemented to prevent continued wandering of Resident #30 in and out of other residents' rooms and the failure of a Certified Nursing Assistant (CNA) to separate Resident #30 and Resident #65 when she overheard them arguing in the hallway, with Resident #30 hitting Resident #65 in the head, resulted in psychosocial harm to Resident #65. Resident #30 continued to wander throughout the facility, in and out of other residents' rooms, then entered Resident #45's room, attempted to choke her, and stated she would kill her. The facility's failure to prevent abuse by Resident #30 placed Resident #65 and Resident #45 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements for participation has caused, or is likely…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2021-07-13 · tag F0609 — failed to report abuse allegations — widespread
  Timely 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, and interview, the facility failed to timely report to the State Survey Agency an allegation of abuse for 2 residents (Residents #65 and #45) and failed to timely report an allegation of abuse to Administration for 1 resident (Resident #45) of 16 residents reviewed for abuse. Resident #30 hit Resident #65 in the head. Resident #30 continued to display wandering and aggressive behavior and entered Resident #45's room and attempted to choke Resident #45. The facility's failure to ensure allegations of abuse were reported timely placed all residents in the facility in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements for participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) in the conference room on 7/10/2021 at 12:50 PM. The facility was cited F-609 at a scope and severity of L which constitutes…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · L2021-07-13 · tag F0610 — failed to investigate and act on abuse reports — widespread
  Respond 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, and interview, the facility failed to investigate an allegation of abuse for 2 residents (Resident #30 and #65) of 16 residents reviewed for abuse when a Certified Nursing Assistant (CNA) failed to separate Resident #30 and Resident #65 when she overheard them arguing in the hallway, which resulted in a resident to resident altercation when Resident #30 hit Resident #65 in the head. This resulted in psychosocial harm for Resident #65. Resident #30's continued wandering led to Resident #30 entering Resident #45's room and attempting to choke Resident #45 and stating she would kill Resident #45. The facility's failure to recognize and investigate resident to resident abuse that occurred between Resident #30 and Resident #65 placed Resident #65 and Resident #45 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements for participation has caused, or is likely to cause serious injury, harm, impairment, or death to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · L2021-07-13 · tag F0741 — failed to have staff trained for behavioral health — widespread
  Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
  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 staff had the knowledge and skill set required to develop appropriate behavior health care plans and provide care to meet the behavioral health needs of 2 residents (#30 and #65) of 4 residents reviewed for behaviors. The facility's failure to have competent staff to implement appropriate behavioral interventions resulted in an altercation between Resident #30 and Resident #65 where Resident #65 suffered psychosocial harm. Resident #30's continued wandering behavior led to Resident #30 wandering into Resident #45's room and placing her hands-on Resident #45's neck and attempting to choke her. The facility's failure to ensure staff were knowledgeable and competent to provide services for residents with behavior care needs placed Resident #30 and Resident #65, and Resident #45 in Immediate Jeopardy (a situation in which the providers non-compliance with one or more requirements for participation has…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · L2021-07-13 · tag F0744 — failed to care for residents with dementia — widespread
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
  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 develop and implement individualized care plan interventions to include and support each resident's Dementia care needs for 5 residents (Residents #30, #65, #41, #43, and #46) of 7 residents reviewed for Dementia care. The facility's failure to develop, implement and maintain individualized care plans for Dementia care needs resulted in a resident to resident altercation between Resident #30 and Resident #65 with Resident #30 hitting Resident #65 in the head resulting in psychosocial harm for Resident #65. Resident #30's continued wandering led to Resident #30 entering Resident #45's room, attempting to choke her, and stating she would kill her. The facility's failure to develop, implement and maintain an individualized, resident-centered care plan for Residents' #30, #65, #41, #43, and #46 placed Residents #30, #65, and #45 in Immediate Jeopardy (a situation in which the provider's non-compliance with one…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2021-07-13 · tag F0867 — failed to act on quality-improvement findings — widespread
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, medical record review, and interview, the facility's Quality Assurance Performance Improvement (QAPI) program failed to identify a quality deficiency and implement interventions to address the root causes of a resident to resident altercation when Resident #30 hit Resident #65 in the head, which led to psychosocial harm to Resident #65.The facility's failure to investigate an instance of resident to resident abuse and to implement individualized, person-centered behavior interventions for Resident #30's continued wandering throughout the facility resulted in Resident #30 later entering Resident #45's room and placing her hands on the resident's neck and attempting to choke Resident #45. The facility's QAPI program's failure to identify, develop, and implement interventions to protect all residents from Resident #30's continued wandering and potential abuse placed all residents in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0552 — isolated
  Ensure that residents are fully informed and understand their health status, care and treatments.
  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 resident or resident representative consented to the use of psychotropic medications prior to administration of the medication for 1 resident (Resident #19) of 5 residents reviewed for unnecessary medications.The findings include: Review of the facility's undated policy titled, Psychotropic Medication Use Guidelines, revealed .Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions . Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Dementia, Psychosis, Depression, and Anxiety Disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Review of a Medication…

  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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately 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, transportation calendar review, and interviews, the facility failed to notify a resident representative of appointments outside of the facility for 1 resident (Resident #1) of 3 resident families interviewed for notifications. The findings include: Review of the facility's undated policy titled, Transporting a Resident, revealed .Facility will ensure that residents who require an escort to appointments, due to cognitive or physical limitations, have arrangements made ahead of time. The facility will notify the family of the appointment . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia, Cerebral Infarction (stroke), and Hemiplegia (paralysis of one side). Review of a comprehensive care plan for Resident #1 dated 10/22/2023, revealed .Cognition .I have problems with my memory and cognition . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1…

  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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0604 — failed to not use physical restraints improperly — isolated
  Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  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 obtain a physician's order for the use of a seatbelt, failed to perform an assessment for the use of a seatbelt, and failed to identify medical symptoms that would require the use of a seatbelt for 1 resident (Resident #13) of 1 resident reviewed for physical restraints. The findings include: Review of the facility's undated policy titled, Restraint Free Environment Guidelines, revealed .The facility .limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints .A physician's order alone is not sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the determination to use a restraint .Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine .How the use of restraints would treat the medical…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview the facility failed to provide a rationale for the continued use of an as needed (PRN) antianxiety medication beyond 14 days for 1 resident (Resident #19) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility's undated policy titled, Psychotropic Medication Use Guidelines, revealed .PRN orders all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. [that is] 14 days) .If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order . Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Unspecified…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide 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, and interviews, the facility failed to obtain a physician's order and assess a resident's ability to perform tracheostomy (surgical opening into the windpipe) self-care for 1 resident (Resident #2) of 1 resident reviewed for tracheostomy.The findings include: Review of the facility's undated policy titled, Care Services and Resident Choices & [and] Preferences, revealed .As appropriate, the residents will be involved in .the implementation of interventions and administration of care .While allowing residents to exercise his/her autonomy, the facility is responsible to determine if the residents' choice presents a risk or safety challenge to the resident .It is the resident's right to determine what, if anything, they would prefer to do or not to do each day in accordance with physician orders and resident's abilities . Review of the facility's undated policy titled, Tracheostomy Care Guidelines, revealed .The facility will ensure that residents who need…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0850 — failed to provide social-work services — isolated
  Hire a qualified full-time social worker in a facility with more than 120 beds.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on facility policy review, facility documentation review, and interviews, the facility failed to employ a qualified social worker on a full-time basis.Review of the facility's undated policy titled, Social Services guidelines, revealed .A facility will employ a social worker on a full-time basis . Review of a facility typed document dated 2/12/2026, signed by the Administrator revealed from 5/9/2025 to 5/27/2025, 6/10/2025 to 8/11/2025, 10/8/2025 to 11/26/2025, and from 1/5/2026 to current (2/12/2026) the facility did not employ a qualified social worker for approximately 167 days or 5.5 months out of 9 months reviewed. During an interview on 2/10/2026 at 8:15 AM, the Social Worker stated .I [Social Worker] started here [employed by the facility] in October .it was the 13th [10/13/2025] .I was concierge from October 13th thru January the 5th .now I am the Social Worker .no I don't have a social worker degree or training .I am helping out with the social worker stuff until they get [hire] a social worker . During an interview on 2/12/2026 at 12:30 PM, the Administrator…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-05 · tag F0657 — failed to keep the care plan current — isolated
  Develop 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 documentation review, medical record review, and interview the facility failed to have the minimum required disciplines attend the Interdisciplinary (IDT) care plan meetings for 1 (Resident #1) of 4 residents reviewed for care plan timing and revision. The findings include: Review of the facility policy titled, Care Planning - Interdisciplinary Team, revised 3/2022, revealed .The interdisciplinary team is responsible for the development of resident care plans .The IDT includes but is not limited to .the residents attending physician .a registered nurse .a nursing assistant .a member of the food and nutrition services .resident and or the resident's representative .other staff as appropriate . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Hepatic Encephalopathy, Alcoholic Cirrhosis of Liver with Ascites, Dependance on Renal Dialysis, and Esophageal Varices. Resident #1 was discharged to the hospital 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-23 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to administer a feeding tube formula (liquid nutrition delivered through a tube inserted into the stomach) as ordered by the physician for 1 resident (Resident #1) of 2 residents reviewed for tube feeding nutrition. The findings include: Review of the facility's undated policy titled, Feeding Tube guidelines, revealed .Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders . Review of the medical record revealed, Resident #1 was admitted to the facility on [DATE] with diagnoses including Stroke, Epilepsy, Type 2 Diabetes, Gastrointestinal (GI) Bleed, Dysphagia (difficulty swallowing), and Aphasia. Review of the Physicians Order for Resident #1 dated 10/16/2024, revealed .Glucerna [tube feeding liquid nutrition] 1.5 at 70ML/HR [milliliters per hour] Water Flush 45ML/HR x [times] 22 hrs [hours] .Pleasure pureed [pudding like consistency], thin liquid tray…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-11-18 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observations and interviews, the facility failed to maintain a clean, comfortable, and home like environment for 5 hallways of 5 hallways observed for comfortable and home like environments. The findings include: Review of the facility policy titled, Resident Environmental Quality, undated, revealed The facility will be .maintained to provide a safe, functional .and comfortable environment for residents .Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy .Preventive maintenance .should be followed . During an observation on 11/3/2024 at 11:40 AM, revealed the 100-hallway carpet had multiple large stains in various places from unidentified substances, which included various shades of brown stains and bright red stains. During an observation on 11/3/2024 at 11:42 AM, revealed the 200-hallway carpet had multiple large stains in various places from unidentified substances, which included various shades of brown stains and bright red stains.…

  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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-11-18 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on facility policy review, observations, and interviews, the facility failed to discard expired food in 1 of 1 kitches which had the potential to affect 99 of 99 residents. The findings include: Review of the facility's policy titled, Food Safety Guidelines, undated, revealed .The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded . During an observation of the food preparation area on 11/3/2024 at 9:45 AM, with the Certified Dietary Manager (CDM), revealed the following: 1. 80 ounce opened bag of grits contained in sealed storage bag with opened date: 9/18/2024 and discard date: 10/18/2024 and available for use. 2. An unopened 4-pound roll of deli bologna with received date as: 8/16/2024 and use by date: 9/3/2024 and available for use. 3. 12 ounce container of ground black pepper that was opened to air and available for use. 4. 12 ounce container of ground allspice sealed with open date of 6/1/2024 and discard date of 8/1/2024 and available for use. During an observation and interview on 11/3/2024 at 10:19 AM, the CDM…

  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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

$250,780 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $250,780 — penalty dated 2024-11-18
• Medicare payment denial — starting 2024-11-28 for 72 days

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.

Who owns this facility

CMS files one row per role, so the 10 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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 $545K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TN