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Park Meadows Post Acute

900 Professional Park Drive, Clarksville, TN 37040 · For profit - Corporation · 113 certified beds · (931) 552-3002 Medicare & Medicaid certified

Call the home — (931) 552-3002 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 21 lower-level deficiencies on record (see below)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (66%) runs well above the national median (45%)
  • about 27% of its spending goes to commonly-owned related companies
  • its last standard health inspection was over 4 years ago — the star rating may not reflect current conditions

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Urgent care / clinic
881 Professional Park Dr · (931) 645-4685 · Call to confirm hours
Pharmacy
620 Dunlop Ln # 110 · (931) 278-6422 · Call to confirm hours
Grocery
2809 Wilma Rudolph Blvd · (931) 552-5501 · Call to confirm hours
Park
650 Bellamy Ln · (931) 553-4070 · Typically dawn to dusk
Place of worship
290 Warfield Blvd · (931) 647-1324

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 2 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 1 to 2 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.9%14.0%15.4%typical
Long-stay residents who lose too much weight3.1%6.1%5.4%better
Long-stay residents with a catheter left in their bladder1.2%0.7%0.9%worse
Long-stay residents with a urinary tract infection2.1%1.8%2.0%typical
Long-stay residents with depressive symptoms56.4%13.8%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.0%3.4%3.3%better
Long-stay residents whose ability to walk worsened29.9%17.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication46.8%31.7%18.9%worse
Long-stay residents given the seasonal flu vaccine90.9%94.5%95.3%typical
Long-stay residents with pressure ulcers6.4%5.0%4.7%worse
Long-stay residents with worsening bladder/bowel control28.6%20.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table11.1%16.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.0%1.7%1.4%better
Short-stay residents given the seasonal flu vaccine66.5%79.8%79.4%worse
Short-stay residents rehospitalized after admission27.3%22.6%22.6%worse
Short-stay residents with an outpatient ER visit9.5%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days2.041.671.67worse
Long-stay outpatient ER visits per 1,000 resident days1.151.561.80better

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.

46.6% 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 170 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.6%U.S. median 51.5%
Got home and stayed home
15.5%U.S. median 10.7%
Went back to hospital
55.1%U.S. median 56.6%
Met the expected recovery
0.50U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.25hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 55.1% 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 98 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 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF46.6%CMS range 40.0–54.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF15.5%CMS range 11.4–19.910.7%Oct 2022–Sep 2024worse than U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge55.1%56.6%Oct 2024–Sep 2025CMS 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 discharge66.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge57.1%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.4%CMS range 5.6–12.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.061.02Oct 2022–Sep 2024CMS 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

0.50
RN hours/ resident / day
1.65
LPN hours/ resident / day
3.00
Aide hours/ resident / day
5.15
Total nurse hours/ resident / day
0.53
RN hoursweekends
65.9%
Total nursing turnover
75.0%
RN turnover

How full it usually is: this home is certified for 113 beds and averages 108.2 residents a day — about 96% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. 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 5.15 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.00 is at or above 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 5.28 hrs/resident/day on weekends vs 5.09 on weekdays — about the same on weekends as weekdays. RN hours go from 0.48 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 66% is well above 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

11
deficiencies at the latest standard inspection (2022-05-04)
8
at the previous standard inspection (2019-11-06)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 4 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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.

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · Fcited before2022-05-04 · 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 policy review, observation, and interview, the facility failed to ensure food was stored, prepared and served under sanitary conditions as evidenced by opened and undated food items, staff wearing mask below their nose, and staff handling plates with their bare hands. The facility had a census of 95, with 92 of those residents receiving a meal tray from the kitchen. The findings include: The facility's policy titled, Dietary: Food Service, dated 7/12/2021, revealed .Opened food items . should be stored in a closed container to prevent contamination . Observation in the Kitchen on 5/2/2022 beginning at 10:29 AM, revealed the following: a. a plastic container with cornmeal unlabeled and undated b. a plastic container with flour unlabeled and undated c. a plastic container with sugar unlabeled and undated Observation in the Kitchen on 5/3/2022 beginning at 7:57 AM, revealed the following: a. The Regional Registered Dietician standing in the Kitchen talking with the Surveyor without her mask on. b. The Regional Director of Nutritional Services walking from the back of 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-05-04 · tag F0661 — pattern
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    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 policy review, medical record review, and interview, the facility failed to ensure the completion of a Discharge Summary with a recapitulation of the resident's stay, the disposition status of the resident at the time of discharge, a post discharge plan of care, and a Physician's Order for discharge for 4 of 4 sampled residents (Resident #98, #100, #251, and #252) reviewed for discharge. The findings include: Review of the facility's policy titled, Transfer and Discharge, revised on 11/2021, revealed .Orientation for transfer or discharge must be provided and documented to ensure safe and orderly transfer or discharge from the facility .Other necessary information, including a copy of the resident's discharge summary .to ensure a safe and effective transition of care .Obtain physician's order for transfer or discharge and instructions or precautions for ongoing care .A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time…

    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 · Ecited before2022-05-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to ensure investigations, neurological (neuro) checks, and assessments were completed for 3 of 3 sampled residents (Resident #11, #28, and #248) reviewed for falls. The findings include: Review of the facility's policy titled, Fall Risk - Fall Prevention, revised on 2/20/2020, revealed .To provide a coordinated system to identify Residents at risk for falls .The fall risk assessment will be completed by a licensed nurse .After a fall . Review of the medical record, revealed Resident #11 was admitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Hepatitis, Heart Disease, and Schizophrenia. Review of the Clinical Note dated 1/11/2022, revealed .CNA [Certified Nursing Assistant] discovered resident [Resident #11]on floor. Resident noted to be sitting up on floor next to bed. When asked resident stated she wasn't sure what happened . Review of the annual Minimal Data Set (MDS) assessment dated [DATE], revealed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-04 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    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 ensure 2 of 19 sampled residents (Resident #93 and #148) or their families were invited to participate in planning their care. The findings include: Review of the medical record, revealed Resident #93 was admitted to the facility on [DATE] with diagnoses of Epilepsy, Chronic Kidney Disease, Osteoarthritis, and Cerebral Infarction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #93 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Review of the medical record, revealed Resident #93's last Care Plan meeting was held on 4/29/2021. Review of the medical record, revealed Resident #148 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease Stage 3, Osteoarthritis, and Age-related Cognitive Decline. Review of the quarterly MDS assessment dated [DATE], revealed Resident #148 had a BIMS score of 12, which indicated she had moderate…

    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 · D2022-05-04 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to develop an Advance Directive for 4 of 19 sampled residents (Resident #28, #56, #66 and #91) reviewed for Advance Directives. The findings include: Review of the facility's policy titled, .Advance Directives ., revised on 10/18/2021, revealed .Resident will be informed, and written information provided, during the admission process, regarding the right to accept or refuse medical or surgical treatment . Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses of Dementia, Anxiety, Hypothyroidism, and Cognitive Deficit. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated she was moderately cognitively impaired. Review of Resident #28's medical record, revealed there was no Advance Directive present and there was no…

    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 · Dcited before2022-05-04 · 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 policy review, medical record review, and interview, the facility failed to revise the Care Plan to reflect the residents' current status for 2 of 2 sampled residents (Resident #11 and #28) reviewed for falls. The findings include: Review of the facility's policy titled, Fall Risk- Fall Prevention, revised on 2/20/2020, revealed .An 'At Risk For Fall' care plan may need to be created or updated for Residents .after a fall .quarterly .to address items identified on the fall risk assessment as needed .Scheduling IDT [Interdisciplinary Team] care plan meetings to review the plan of care and include the Resident's risk for falls and current interventions to reduce/eliminate falls . Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with a diagnoses of Chronic Obstructive Pulmonary Disease, Hepatitis, Heart Disease, and Schizophrenia. Review of the Care Plan dated 1/2/2022, revealed Resident #11 was at risk for falls related to Cerebral Vascular Accident with…

    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 · D2022-05-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to ensure a resident was assisted with Activities of Daily Living (ADLs) for 1 of 1 sampled resident (Resident #8) reviewed for ADLs. The findings include: Review of medical record, revealed Resident #8 was admitted to facility on 10/15/2021 with diagnoses of Respiratory Failure, Heart failure, Depression, Anxiety, Dementia, and Benign Prostatic Hypertrophy. Review of the Care Plan dated 1/28/2022, revealed .Self care deficit .bathing .hygiene .bathing 3 times per week .Assist resident with dressing .Assist with hygiene .Assist with combing/fixing hair . Review of quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated he was moderately cognitively impaired, required extensive to total assistance from staff for ADLs except supervision for eating, and was totally dependent upon staff for bathing. Review of the ADL Verification Worksheet…

    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 · D2022-05-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 policy review, medical record review, and interview, the facility failed to provide Physician Orders for an indwelling urinary catheter for 2 of 2 sampled residents (Resident #15 and #46) reviewed for indwelling urinary catheters. The findings include: Review of the facility's policy titled, Indwelling Urinary Catheter, revised on 3/30/2022, revealed .The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary, size of the catheter, and frequency of change . Review of the medical record, revealed Resident #15 was admitted to the facility on [DATE] with diagnoses of Dementia, Palliative Care, and Benign Prostatic Hyperplasia. Review of the Care Plan dated 8/24/2021, revealed Resident #15 was at risk for infection related to indwelling catheter and urinary retention. Review of the Physician's Orders dated 10/12/2021, revealed .Maintain indwelling catheter .Catheter site care .Change…

    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 · Dcited before2022-05-04 · 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 policy review, medical record review, and interview, the facility failed to document meal percentages for 1 of 5 sampled residents (Resident #74) reviewed for nutrition. The findings include: Review of the facility's policy titled, Dietary: Weight Monitoring, revised on 11/9/2021, revealed .Documentation: Meal consumption information should be recorded . Review of the medical record, revealed Resident #74 was admitted to the facility on [DATE] with diagnoses of Dementia, Mild Cognitive Impairment, Anxiety, Age-related Physical Debility and Cognitive Decline, and Malignant Neoplasm of Prostate. Review of the Activity of Daily Living (ADL) Verification Worksheet dated 3/1/2022- 5/4/2022 revealed the following meal intakes were not documented: a) 3/1/2022 no documentation for breakfast and dinner. b) 3/2/2022 no documentation for breakfast and lunch. c) 3/17/2022 no documentation for breakfast and lunch. d) 4/4/2022 no documentation for breakfast and lunch. e) 4/5/2022 no documentation for lunch and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-04 · 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 medical record review, observation, and interview, the facility failed to follow the Physician Orders for oxygen flow rate for 1 of 1 sampled resident (Resident #8) reviewed for respiratory services. The findings include: Review of the medical record, revealed Resident #8 was admitted to facility on 10/15/2021 with diagnoses of Respiratory Failure, Heart failure, Depression, Anxiety, Chronic Pain, and Dementia. Review of the Physician Orders dated 10/16/2021, revealed .Oxygen [O2] at 2L/min [liters per minute] per nasal cannula [tube inserted into the nose with prongs to deliver oxygen] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated he was moderately cognitively impaired and he received oxygen therapy. Observation in the Dining Room on 5/2/2022 at 11:32 AM, revealed Resident #8 was receiving oxygen per nasal cannula at 0 L/min. Observations in resident's room on 5/2/2022 at 2:55…

    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
Show the remaining 11 citations
  • Potential for harm · D2022-05-04 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored in 2 of 95 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) when medications were found at the bedside unattended and unsecured during the facility tour. The findings include: Review of the facility's policy titled, Medication Administration: Medication, Controlled and Biological Storage, Night/Emergency Box and Backup Pharmacy, dated 9/20/2021, revealed .All drugs and biologicals will be stored in locked compartments ( .medication carts, cabinets, drawers, refrigerators, medication rooms) . Observation in room [ROOM NUMBER] during the facility tour on 5/2/2022 beginning at 11:50 AM, revealed the following medications on the night stand unattended and unsecured: a. 5 packages of peri guard ointment [moisture barrier ointment to prevent skin breakdown] on the nightstand b. 3 normal saline sodium flushes [irrigation used for cleaning wounds] c. 5 Bisacodyl suppositories [medicated…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-11-06 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to provide a dignified environment for 4 of 4 (Resident #67, #73, #297, and #298) sampled residents reviewed with an indwelling urinary catheter. The findings include: 1. The facility's .Promoting/Maintaining Resident Dignity . policy dated 11/17 documented, .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life .Maintain resident privacy . 2. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with diagnoses of Retention of Urine and Pressure Ulcer. The Physician's Order dated 4/8/19 documented, .Maintain indwelling catheter . Observations in Resident #67's room on 11/4/19 at 11:36 AM, and 1:04 PM, revealed the resident had an uncovered indwelling catheter bag with urine present. 3. Medical record…

    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 · Dcited before2019-11-06 · 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 medical record review, observation, and interview, the facility failed to ensure care plans were revised related to nutrition and catheter care for 3 of 24 (Resident #9, #67, and #73) sampled residents reviewed. The findings include: 1. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Diabetes, Hypothyroidism, Seizures, Hypertension, Dementia, Anxiety Disorder, Chronic Obstructive Pulmonary Disease and Major Depressive Disorder. The Care Plan with a goal date of 1/13/20 documented, .Weight loss .[Named Resident #9] to eat all meals in the dining room . Observations in Resident #9's room on 1/5/19 at 7:56 AM and 11/6/19 at 8:04 AM, revealed Resident #9 eating her meal in her room. Interview with the Director of Nursing (DON) on 11/6/19 at 2:32 PM, in the DON Office, the DON was asked where Resident #9 ate her meals. The DON stated, She [Resident #9] eats in her room a lot now. The DON was asked if the care plan was correct 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-11-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 policy review, medical record review and interview, the facility failed to provide timely assessments for pressure ulcers for 1 of 2 (Resident #33) sampled residents reviewed with pressure ulcers. The findings include: The facility's Pressure Injury Prevention and Non-Pressure Ulcer Management policy dated 11/2019 documented, .Assessments of pressure injuries will be performed by a licensed nurse and documented on the Weekly PUPI [Pressure Ulcer Pressure Injury] Assessment form . Medical record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses of Unspecified Fall, Diabetes, Hypertension, Atrial Fibrillation, Obesity, Vitamin D Deficiency, Depressive Episodes, Hypothyroidism, Cognitive Deficit, Chronic Pain, and Pressure Ulcer. The Care Plan with a goal date of 12/5/19 documented .Stage 3 pressure ulcer . The WOUND AND PRESSURE INJURY INFORMATION form did not document weekly wound assessments on the following dates: a. the week of 5/20/19 b. the week of 5/27/19 c. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-11-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, investigation worksheet review, observation, and interview, the facility failed to initiate appropriate fall interventions and accurately assess residents for fall risk for 2 of 4 (Resident #9 and #349) sampled residents reviewed for falls. The findings include: 1. The facility's Fall Risk/Fall Prevention Guidelines policy dated September 2014 documented, .Patients and patient care areas are assessed for the risk of accident and injury and plans to protect all patients from accidental and injury are based on the assessment .Patients that are newly admitted to a facility are often times at high risk for falls. Identifying potential risk factors can assist in preventing falls .High risk fall identifiers, such as Falling Star, Falling Leaf, or other facility prevention programs .Attempt to determine the cause of the event, update the Fall Risk Assessment Tool . 2. The facility's Fall Risk Assessment policy revised 11/2017 documented, .To provide a coordinated system 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-11-06 · 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 medical record review, observation, and interview, the facility failed to perform nutritional assessments for 1 of 5 [Resident #9] sampled residents reviewed for weight loss. The findings included: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Dysphagia, Diabetes, Hypothyroidism, Hypertensive, Psychotic Disorder, Dementia, Anxiety, Chronic Obstructive Pulmonary Disease, and Depression. The annual Minimum Data Set (MDS) dated [DATE] and a quarterly MDS dated [DATE] documented Resident #9 had severe cognitive deficits, had no swallowing disorders, and was not on a physician weight loss regimen but had weight loss. Medical record review revealed there were no nutritional assessments completed for April 2019 and July 2019. Interview with the Registered Dietician (RD) on 11/6/19 at 1:25 PM, in the Dietary Office, the RD was asked how often a nutritional assessment should be done for Resident #9. The RD stated, .nutritional assessments…

    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 · D2019-11-06 · tag F0697 — failed to manage pain — isolated
    Provide 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 medical record review and interview, the facility failed to administer pain medication as ordered for 1 of 5 (Resident #298) sampled residents reviewed for pain. The findings include: Medical record review revealed Resident #298 was admitted to the facility on [DATE] with diagnoses of Bacteremia, Cellulitis of the Right Lower Limb, Low Back Pain, Pain in Left Lower Leg, Pain in Right Lower Leg, Paraneoplastic Neuromyopathy, and Neuropathy. The Care Plan dated 10/21/19 documented, .Pain Management .Institute associated medical orders, administer analgesics . The admission Orders from (Named Hospital) dated 10/15/19 documented, .oxyCODONE (oxyCODONE 10 mg [milligrams] oral tablet) = 1 tab(s) [tablets], Oral, q [every]4H [Hours] .Start: 10/15/19 9:18 AM .(oxy CODONE 40 mg oral tablet, extended release [ER]) = 1 tab(s), Oral, q12H .Start 10/15/19 09:19 [9:19 AM] . Interview with Resident #298 on 11/5/19 at 9:06 AM, in her room, Resident #298 stated that she did not receive her pain medication as she should…

    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 · Dcited before2019-11-06 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to maintain safe and sanitary hydration supplies for 1 of 1 (Resident #347) sampled residents reviewed on thickened liquids when hydration supplies were not maintained appropriately by the bedside for 2 of 3 (11/4/19 and 11/5/19) days of observations. The findings include: The facility's .Dietary: Availability of Liquids To Meet Resident Need, Preferences, Hydration . policy dated 9/19 documented, .All perishable foods will be stored at proper temperatures .Leftover foods are stored in appropriate containers so that the interior temperature of the food chills quickly .They are covered, labeled and dated . Medical record review revealed Resident #347 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Diabetes, and Dysphagia. Observations in Resident #347's room on 11/4/19 at 10:45 AM, 12:30 PM, and 11/5/19 at 8:06 AM, revealed open and undated assorted thickened beverages in a cooler,…

    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
  • Potential for harm · D2019-11-06 · tag F0880 — failed to prevent and control infections — isolated
    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 policy review, medical record review, observation, and interview, the facility failed to ensure practices were followed to prevent the potential spread of infection during medication administration when 2 of 4 (Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1) nurses administered dropped medication and failed to clean nebulizer supplies after use. The findings include: 1. The facility's Infection Prevention and Control Program policy dated 5/2019 documented, .reusable equipment will be decontaminated using a germicidal detergent prior to storing 2. The facility's Nebulizer Treatment policy dated 4/2019 documented, .Rinse nebulizer cup with warm, tap water, shake off excess water, allow to air dry and place in storage bag . 3. Medical Record Review revealed Resident #297 was admitted to the facility on [DATE] with diagnoses of Dysphagia, Hemiplegia, Esophageal Reflux Disease, and Altered Mental Status. The Physician's Orders dated 11/2019 documented, .Famotidine 20 mg [milligrams] tablet…

    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
  • Potential for harm · D2019-01-24 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview the facility failed to ensure an accurate Minimum Data Set (MDS) assessment was completed for dialysis, antipsychotic medication use, and indwelling urinary catheter for 3 of 23 sampled residents (Resident #13, #29, and #158). The findings include: 1. Medical record review documented Resident #13 was admitted to the facility on [DATE] with diagnoses of Hypertensive Heart Disease, Diabetes Mellitus, End Stage Renal Disease, and Renal Dialysis. Review of the annual MDS assessment dated [DATE] documented the facility failed to code Resident #13 for receiving dialysis services. The Physician Order Sheet January 2018 documented, .Dialysis Monday-Wednesday-Friday .End Stage Renal Disease .Continuous Starting 02/26/2018 . Interview with MDS Coordinator #1 on 1/24/19 at 10:10 AM in the MDS Office, MDS Coordinator #1 was asked if Resident #13 received dialysis services. MDS Coordinator #1 stated, Yes, ma'am, she does. MDS Coordinator #1 was then asked if Resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-01-24 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the American Society of Consultant Pharmacists GERIATRIC MEDICATION HANDBOOK, THIRTEENTH EDITION, medical record review, observation, and interview, the facility failed to ensure nursing standards of practice were followed when 1 of 5 (Licensed Practical Nurse (LPN) #1) nurses used bare hands to administer a transdermal analgesic patch. The findings include: Review of the American Society of Consultant Pharmacists GERIATRIC MEDICATION HANDBOOK, THIRTEENTH EDITION with a revision date of 8/16, page 60, documented, .Administering Transdermal Patches .Apply to the skin, pressing firmly for approximately ten (10) seconds .Remove gloves . Medical record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of Gastrostomy, Hemiplegia, Muscular Dystrophy, Cerebrovascular Disease, Congestive Heart Failure, Dementia, Hypothyroidism, Convulsions, and Depression. The physician's orders dated 1/7/19 documented, .fentanyl 12 mcg [micrograms] patch [a pain relieving patch] place…

    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

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — 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.

$11.3M
Net patient revenuemost recent cost report
-26.9%
Operating marginrevenue minus expenses
$3.9M
Related-party expense27% of expenses
Who pays — share of resident-days
Medicaid 76%Medicare 9%Other / private 15%

About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.9M paid to related parties — landlords or management companies under common ownership — equal to about 27% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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

$378per resident / day
operating cost
$11,493per month
≈ monthly operating cost
$298per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Tennessee
$9,429/mo
Nursing home (semi-private)
$10,038/mo
Nursing home (private)
$5,845/mo
Assisted living

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 445455. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2022-05-04, 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.

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