Spring Meadows Health and Rehabilitation

Location & what’s nearby

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

Quality measures — how residents actually fare

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.

46.7% 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 109 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 42.5% 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 80 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 0.20 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 26% 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 121 beds and averages 110.4 residents a day — about 91% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 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 3.20 hrs/resident/day on weekends vs 3.52 on weekdays — 9% thinner on weekends. RN hours go from 0.63 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are 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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 15 most serious are shown; the remaining 6 are one tap away and print in full.

• Immediate jeopardy · J2022-07-25 · tag F0609 — failed to report abuse allegations — isolated
  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 weather website review, policy review, medical record review, observation, and interview, the facility failed to report incidents of elopement for 2 of 7 sampled residents (Resident #45 and #87) reviewed for wandering and elopement. The facility's failure to report incidents of elopement to the State Survey Agency resulted in Immediate Jeopardy when Resident #45, a vulnerable, severely cognitively impaired resident, exited the facility without staff knowledge or supervision and was found approximately 94.6 feet from the New Wing North exit door, standing in the parking lot on a cold January day, out of sight of the staff for approximately five to ten minutes and when Resident #87 a vulnerable, moderately cognitively impaired resident exited the facility without staff knowledge or supervision and was found leaning against the building, outside the New Wing South exit door, at approximately Midnight, out of sight of the staff for an undetermined amount of time. Immediate Jeopardy (IJ) is a situation in…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2022-07-25 · tag F0610 — failed to investigate and act on abuse reports — isolated
  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 policy review, job description review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure incidents of elopement, staff-to-resident abuse, and drug diversions were thoroughly investigated for 5 of 10 sampled residents (Resident #45, #87, #19, #68, and #90) reviewed for wandering/elopement behaviors and at risk for abuse. The facility's failure to thoroughly investigate incidents of elopement resulted in Immediate Jeopardy when Resident #45, a cognitively impaired resident at risk for wandering/elopement, exited the facility without staff knowledge, walked approximately 94.6 feet from the facility, and was found standing in the parking lot in the back of the facility and when Resident #87 a vulnerable, moderately cognitively impaired resident exited the facility without staff knowledge or supervision and was found leaning against the building, outside the New Wing South exit door, at approximately Midnight, out of sight of the staff for an…

  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 · J2022-07-25 · 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 weather website review, policy review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent elopement for 2 of 7 sampled residents (Resident #45 and #87) reviewed for elopement/wandering behaviors. Resident #45, who had severely impaired cognition, was at risk for wandering, and was a fall risk, exited the facility without staff knowledge through the New Wing North exit door on a cold January day, walked approximately 94.6 feet and was found by staff standing in the parking lot for an undetermined amount of time. Resident #87, who had severely impaired cognition, was at risk for wandering, and was a fall risk, exited the facility without staff knowledge through the New Wing South exit door and was found leaning against the building outside the door, out of view of the staff. The facility's failure to ensure residents at risk for wandering/elopement behaviors were adequately…

  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 · J2022-07-25 · tag F0835 — failed to run the facility competently — isolated
  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

  Based on policy review, Board of Examiners for Nursing Home Administrators (BENHA) review, job description review, and interview, the facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well-being of cognitively impaired residents with wandering behaviors. Administration failed to provide oversight to monitor and provide a safe resident environment for cognitively impaired residents with wandering behaviors, to report, and investigate incidents of elopement. These failures resulted in Immediate Jeopardy when Resident #45, a severely cognitively impaired resident with exit-seeking behaviors, exited the building without staff knowledge or supervision and was found approximately 94.6 feet from an exit door, standing in the parking lot on a cold January day, out of staff sight for five to ten minutes and when Resident #87, a moderately cognitively impaired resident exited the facility without staff knowledge or supervision and was found leaning against 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2022-07-25 · tag F0867 — failed to act on quality-improvement findings — isolated
  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 policy review, job description review, Quality Assurance Performance Improvement (QAPI) reports, medical record review, observation, and interview, the QAPI committee failed to ensure systems and processes were in place that involved tracking/trending, evaluation/reevaluation of interventions, data, and trends to address quality concerns related to wandering and elopement behaviors. The QAPI committee failed to ensure a thorough investigation of a resident elopement, failed to identify quality deficiencies and effective interventions, failed to monitor the effectiveness of the interventions, and failed to assess staff knowledge of the care of residents with wandering/elopement behaviors in order to identify deviations and adverse events when residents exited the facility without staff knowledge. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #45, a cognitively impaired resident assessed as a risk for wandering/elopement left the facility unsupervised and was found in the back…

  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 · Ecited before2024-07-11 · tag F0880 — failed to prevent and control infections — pattern
  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 proper infection control practices for 1 of 2 (Resident #20) residents reviewed for isolation precaution. The facility had a census of 107. The findings include: 1. Review of the facility's policy titled, Transmission Based (Isolation) Precautions, dated 6/4/2024, revealed, Signage that includes instructions for use of specific PPE [personal protective equipment] will be placed in a conspicuous location outside of the resident's- room .either the CDC [Centers for Disease Control] category of transmission-based precautions .contact, droplet, or airborne .or instructions to see the nurse before entering will be included in the signage .Contact Precautions .Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment . Review of the facility's undated policy titled, Recommendations for Personal Protective Equipment (PPE), 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-07-11 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  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

  Based on policy review, observation, and interview, the facility failed to provide effective maintenance services to ensure a safe, functional, and comfortable environment as evidenced by the disrepair of the bathroom flooring for 1 out of 104 occupied resident's rooms. The findings include: 1. Review of the facility's policy, titled, Preventive Maintenance, with a date of 3/1/2023, revealed, .A Preventive Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environmental for residents, staff, and the public .The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a sage and operable manner . 2. Observations and interview in the resident's room on 7/08/2024 at 11:20 AM, 7/09/2024 at 8:00 AM, and on 7/09/2024 at 3:33 PM, revealed in Resident #17's bathroom was a large area of missing pieces of linoleum in multiple places around the resident's toilet. Resident #17 confirmed the bathroom floor…

  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 · D2024-07-11 · tag F0640 — isolated
  Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete resident assessments, using the Centers for Medicare & Medicaid Services-specific RAI (Resident Assessment Instrument) process, within the regulatory time frames for 7 of 28 sampled residents (Resident #5, #17, #22, #48, #76, #86, and #93) reviewed for completion of the MDS resident assessments. The findings include: 1. Review of the MDS 3.0 RAI Manual v (version) 1.17.1 October 2019, page 2-37 revealed .using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames. 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Diabetes, Coronary Artery Disease, Hypertension, Depression, and Polyneuropathy. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/7/2022, revealed Item Z0500B with a completion date of…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-07-11 · 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 ensure a care plan meeting was scheduled for 2 of 2 (Resident #8 and #23) reviewed for care plan meeting. The findings include: 1. Review of the facility's undated policy titled CARE PLANNING - RESIDENT PARTICIPATION, revealed .The facility supports the resident's right to inform of, and participate in, his or her care planning and treatment .The facility will notify the resident and/or resident representative, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care, as well as changes to the plan of care . 2. Medical record review revealed Resident #8 was admitted [DATE], with diagnoses including Dementia, Depression, Diabetes, Anxiety, and Bipolar Disorder. Review of quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #8 was cognitively intact. During an interview on 7/9/2024 11:20 AM, Resident #8 was asked if she attended the care plan meetings. Resident #8 stated,…

  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 · D2024-07-11 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to ensure followed practitioner orders for a Percutaneous Gastrostomy (PEG) tube feeding and failed to date and label PEG tube feedings for 1 of 2 (Resident #63) sampled residents reviewed for enteral feedings. The findings include: Review of the medical record revealed Resident #63 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Depression, Anxiety, and PEG tube (Percutaneous Endoscopic Gastrostomy tube, a tube inserted into the stomach to deliver food). Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #63 was severely cognitively impaired, total dependence on staff for Activities of Daily Living, and coded for a PEG tube. Review of the facility's Order Review History Report. dated 6/11/2024 - 7/11/2024 revealed, .Enteral Feed Order six times a day Free water flushes 150 ml [milliliters] Q [every] 4H [hours], provides 900 total fluid .Enteral Feed Order every…

  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 · D2024-07-11 · tag F0947 — failed to train nurse aides adequately — isolated
  Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on review of staff in-services and interview the facility failed to ensure the mandatory annual 12 hours of in-services were provided for the Certified Nursing Assistant (CNA) for 12 of 61 staff members (CNA A, B, C, D, E, F, G, H, I, J, K, and L reviewed for in-servicing training. The findings include: 1. Review of the facility's policy titled, CNA REQUIRED TRAINING, dated 3/1/2023, revealed It is the policy of this facility to comply with State and Federal requirements as they pertain to the training, certification, and continuing education if its nurse aides .The facility will provide at least 12 hours of in-service training annually, based on the employment date, not calendar year .Documentation of the in-services will be forwarded to the HR [Human Resource] Director . 2. Review of a list of CNA staff provided by the facility revealed the following: CNA A was hired on 11/30/2022. CNA B was hired on 1/12/2022. CNA C was hired on 9/4/2013. CNA D was hired on 7/22/2020. CNA E was hired on 2/14/2018. CNA F was hired on 6/30/2020. CNA G was hired on 2/3/2021. CNA H was hired 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2022-07-25 · 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 when the oven had build-up of a shiny, brown substance on the inside doors and all sides in the inside of the oven, the coffee machine had a build-up of black splashes and the spout of the coffee machine had a build-up of a dark gray substance, the toaster had a build-up of crumbs, the juice machine had a build-up of a thick, orange, red, and tan substance on the spout and on the sides of the machine, there was a pink, slimy substance on the water curtain of the ice machine in the Dining Room, the stove's grease trap was filled with a black liquid with thick black stringy material and a thermometer floating in it, the stove's drip pan had several particles of dried food and dark grime covering the pan, there was a build-up of a black substance inside the gas oven on all sides, there was thick, dark brown build-up on the can opener, there was a build-up of dark, brown crumbs on top of the deep fryer and inside the deep fryer, 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 · Fcited before2022-07-25 · 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

  Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, review of Employee Screening logs, employee time sheets, agency invoices, and interview, the facility failed to ensure practices to prevent the spread of infection were maintained when 23 of 121 staff members (Dietary Aide #2, #3, and #4, Housekeeper #1, #2, #3, and #4, Licensed Practical Nurse (LPN) #4 and #8, Agency LPN #1, #2, and #3, Certified Nursing Assistant (CNA) #4, #5, #6, and #7, and Agency CNA #1, #2, #3, #4, #5, #6, and #7) failed to complete screening for the prevention and detection of COVID-19 prior to working on 1 of 1 days (7/15/2022) reviewed. This had the potential to affect the 109 residents residing in the facility. The findings include: Review of the facility's undated policy titled, Coronavirus Surveillance, revealed .This facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness .Screening for visitors and staff .Signs or symptoms of a…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2022-07-25 · tag F0578 — failed to honor advance directives / code status — pattern
  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 formulate an Advance Directive to residents or the residents' responsible parties for 21 of 24 sampled residents (Resident #2, #3, #9, #12, #14, #15, #16, #19, #22, #28, #30, #34, #39, #45, #62, #67, #76, #82, #100, #153 and #255) reviewed for Advanced Directives. The findings include: Review of the facility's policy titled, Communication of Code Status dated 2017, revealed .It is the policy of this facility to adhere to residents' rights to formulate advance directives .The facility will follow facility policy regarding a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an Advance Directive . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, Seizures, and Cerebral Infarction. Review of the admission…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2022-07-25 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 4 sampled residents (Resident #37) were free of a significant medication error when 1 of 5 licensed nurses (Licensed Practical Nurse (LPN) #4) administered an incorrect dosage of an anticoagulant medication. The findings include: Review of the facility's undated policy titled, High Risk Medications-Anticoagulants, revealed .Anticoagulant refers to a class of medications that are used to prevent clot extension and formation .Xarelto .Anticoagulants shall be prescribed by a physician or other authorized practitioner with clear indications for use . Review of the facility's undated policy titled, Medication Administration, revealed .Medications are administered by licensed nurses .as ordered by the physician . Review of the facility's undated policy titled, Medication Errors, revealed .The facility shall ensure medications will be administered as follows .according to physician's orders . Review 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.

  Pharmacy Service 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

No federal fines in the current CMS record.

Part of a chain

This home belongs to LYON HEALTHCARE — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 18 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

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 $582K 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