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Collierville Nursing And Rehabilitation, Llc

490 West Poplar Avenue, Collierville, TN 38017 · For profit - Limited Liability company · 114 certified beds · (901) 854-8506 Medicare & Medicaid certified

Call the home — (901) 854-8506 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609) — most recent Feb 2026Resident-funds citation (F0569)Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0569)
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • about 26% of its spending goes to commonly-owned related companies

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 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
346 New Byhalia Rd Ste 3 · (901) 853-1734 · Call to confirm hours
Pharmacy
560 W Poplar Ave · (901) 854-0010 · Call to confirm hours
Grocery
Aldi0.6 mi
523 W Poplar Ave · (855) 955-2534 · Call to confirm hours
Park
440 W Powell Rd · (901) 457-2770 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 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 held steady at 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
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 increased9.0%14.0%15.4%better
Long-stay residents who lose too much weight8.9%6.1%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection0.7%1.8%2.0%better
Long-stay residents with depressive symptoms0.4%13.8%6.5%better 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 injury1.7%3.4%3.3%better
Long-stay residents whose ability to walk worsened9.6%17.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication22.0%31.7%18.9%worse
Long-stay residents given the seasonal flu vaccine78.1%94.5%95.3%worse
Long-stay residents with pressure ulcers11.2%5.0%4.7%worse
Long-stay residents with worsening bladder/bowel control11.6%20.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table14.6%16.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.9%1.7%1.4%worse
Short-stay residents given the seasonal flu vaccine23.5%79.8%79.4%worse
Short-stay residents rehospitalized after admission28.1%22.6%22.6%worse
Short-stay residents with an outpatient ER visit4.6%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days1.361.671.67better
Long-stay outpatient ER visits per 1,000 resident days0.771.561.80better

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.

47.1% 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 104 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.1%U.S. median 51.5%
Got home and stayed home
13.1%U.S. median 10.7%
Went back to hospital
41.2%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 41.2% 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 34 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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 40% 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 SNF47.1%CMS range 37.4–56.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.1%CMS range 8.6–17.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge41.2%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 discharge38.2%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 discharge14.7%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 identified94.1%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened7.8%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 hospitalization7.2%CMS range 4.5–10.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.131.02Oct 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

0.44
RN hours/ resident / day
1.16
LPN hours/ resident / day
1.80
Aide hours/ resident / day
3.39
Total nurse hours/ resident / day
0.37
RN hoursweekends
50.0%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 114 beds and averages 96.3 residents a day — about 84% occupied, or roughly 18 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.80 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 3.03 hrs/resident/day on weekends vs 3.54 on weekdays — 14% thinner on weekends. RN hours go from 0.47 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% 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

2
deficiencies at the latest standard inspection (2026-06-10)
8
at the previous standard inspection (2022-02-25)

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

Inspection deficiencies

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

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.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · E2026-06-10 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, observation, and interview, the facility failed to maintain a clean and sanitary environment in the kitchen when food debris was noted on top of and inside the deep fryer, the floor around the stove, and deep fryer, crumbs and debris in the silverware tray and on metal food prep tables, the deep fryer had oil drippings down its front casing, oil and debris build up and was dripping oil onto the floor, there was a greasy substance on the metal shield between the grill and the deep fryer, the floor was slippery, the wall behind the two-compartment sink and the viewing glass around the steam table had splatter marks, 2 metal prep carts with thick greasy buildup and food debris, and storage bins had food debris and a sticky substance, unsanitary handling of food and food equipment at the steamtable, and when staff was unable to accurately test the chemical level in the 3-compartment sink. The facility's census was 83 and 79 residents received food trays from the kitchen. The findings include: 1. Review of the facility policy titled, Environment, dated…

    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 · Dcited before2026-06-10 · 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 maintain the prevention and spread of infection during catheter care and during Percutaneous Endoscopic Gastrostomy (PEG) medication administration for 2 of 2 (Resident #8 and Resident #80) sampled residents reviewed for the use of an indwelling urinary catheter and medication administration. The findings include: 1. Review of the facility policy titled, Indwelling Catheter Use and Removal, dated 4/2026, revealed .If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards . Review of the facility policy titled, Infection Prevention and Control Program, dated 4/2026, revealed .All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. Review of the facility policy titled, Care and Treatment of Feeding Tubes, dated 4/20/2026, revealed .It is a policy of this facility…

    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 · Dcited before2026-02-13 · 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 policy review, medical record review, facility investigation review, and interview, the facility failed to report allegations of abuse to Adult Protective Service (APS), the Long- Term Care Ombudsman, local law enforcement, and state survey agency, and failed to complete a 5-day follow-up for the state agency for 1 of 4 (Resident #1) sampled residents reviewed for abuse. The findings include: 1. Review of the facility's policy Abuse, Neglect and Exploitation, dated 6/2025, revealed .It is the policy of this facility to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect.Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse.The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-18 · 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 policy review, medical record review, and interview, the facility failed to report an injury of unknown origin for 1 of 3 (Resident #1) sampled residents reviewed for abuse. The findings include: 1. Review of the facility policy titled, Abuse, Neglect and Exploitation, dated 6/2025, revealed . Serious Bodily Injury means an injury involving .impairment of the of the function of a bodily member .requiring medical intervention such as .hospitalization .Abuse Prevention Coordinator in the facility .is responsible for reporting .suspected abuse, neglect .to the state survey agency and other officials in accordance with state law .Reporting .of all alleged violation to the Administrator, state agency, adult protective services .Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve .serious bodily injury .The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-02-25 · 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, Employee Time Punch Reports, Employee Screening Logs, and interview, the facility failed to implement policies to properly prevent and/or contain COVID-19 when 17 of 110 staff members (Licensed Practical Nurse (LPN) #1, #2, #3, #4, Certified Nursing Assistant (CNA) #1, #2, #3, #4, #5, and #6, Respiratory Therapist (RT) #1, #2, #3, #4, #5, and #6, and Maintenance Staff #1) failed to complete screenings for COVID-19 prior to working on 11 of 34 days (2/12/2022, 2/13/2022, 2/14/2022, 2/15/2022, 2/16/2022, 2/18/2022, 2/19/2022, 2/20/2022, 2/21/2022, 2/22/2022, and 2/23/2022) reviewed. This had the potential to affect the 54 residents residing in the facility. The findings include: Review of the Centers for Disease Control and Prevention (CDC) document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/10/2021, revealed .Establish a process to identify anyone entering the facility, regardless 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-02-25 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, employee file review, and interview, the facility failed to implement a written policy to ensure employees were screened for a history of abuse, neglect, exploitation, or misappropriation of resident property prior to being hired for 4 of 8 sampled employees (Respiratory Therapist (RT) #1, the Social Services Director, the Activity Director, and the Medication Aide) reviewed. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 9/3/2021, revealed .Abuse, Neglect and Exploitation .The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation .and misappropriation .Potential employees will be screened for a history of abuse, neglect, exploitation or misappropriation .Background, reference, and credentials' checks shall be conducted on potential employees . Review of RT #1's employee file, revealed there were no reference checks, abuse registry check or criminal background check included in the file. The facility was unable to provide…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-25 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, and interview, the facility failed to ensure the environment was clean, comfortable, and sanitary when fans were covered in a thick layer of gray dust and were in disrepair in 3 of 29 resident rooms (room [ROOM NUMBER], #305, and #307) observed. The findings include: Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment, dated 9/20/2021, revealed .Resident-care equipment can be a source of indirect transmission of pathogens .Reusable resident-care equipment will be cleaned and disinfected Cleaning .is the removal of visible soil from objects and surfaces and normally is accomplished manually or mechanically . Observation in room [ROOM NUMBER] on 2/22/2022 at 11:02 AM and 3:06 PM, and on 2/23/2022 at 7:42 AM and 12:05 PM, revealed a rotating fan with a layer of thick gray dust on the casing. Observation in room [ROOM NUMBER] on 2/22/2022 at 11:12 AM, 2/23/2022 at 7:36 AM and 11:58 AM, and on 2/24/2022 at 11:50 AM and 3:27 PM, revealed 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-25 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 dated October 2019, medical record review, and interview the facility failed to ensure residents were accurately assessed for antipsychotic medication use, Activities of Daily Living (ADLs), and weight loss for 3 of 19 sampled residents (Resident #2, #21, and #35) reviewed. The findings include: Review of the CMS LTC Facility RAI 3.0 User's Manual Version 1.17.1 dated October 2019, pages G-4 and K-4 revealed, .In order to be able to promote the highest level of functioning among residents, clinical staff must first identify what the resident actually does for himself or herself, noting when assistance is received and clarifying the type .and level of assistance .provided by all disciplines .Weight loss can result in debility and adversely affect health, safety, and quality of life .Weight loss may be an important indicator of a change in the resident's health status or…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-25 · 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 policy review, medical record review, observation, and interview the facility failed to ensure residents were assisted with Activities of Daily Living (ADLs) for brushing teeth for 1 of 2 residents (Resident #11) reviewed for dental services. The findings include: Review of the facility's policy titled, Mouth Care, dated 10/20210, revealed .The purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth .The following equipment and supplies will be necessary .Toothbrush .Toothpaste .The following information should be recorded in the resident's medical record .The date and time mouth care was provided . Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Blindness in the Right and Left Eye, Nontraumatic Intracerebral Hemorrhage, Depression, Anxiety Disorder, Dysphagia, Spastic Hemiplegia Left Side, and Diffuse Traumatic Brain Injury. Review…

    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 · D2022-02-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview the facility failed to follow physician's orders for medication administration for 1 of 5 sampled residents (Resident #4) reviewed for unnecessary medications. The findings include: The facility's policy titled, Medication Administration, dated 1/1/2021, revealed .Administer medication as ordered . Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Enterocolitis due to Clostridium Difficile, Chronic Respiratory Failure, Peritoneal Abscess, Congestive Heart Failure, Hypertension, Diabetes Mellitus, and Depression. Review of the Physician's Order dated 11/20/2021, revealed .Lomotil Tablet 2.5-0.025 MG [milligram] .Give 1 tablet via PEG [Percutaneous Endo-gastric] -Tube two times a day for Diarrhea . Review of the medication administration record (MAR) dated 11/1/2021 - 11/30/2021, revealed Lomotil was only documented as given as ordered on 11/19/2021-11/28/2021. Review of the MAR dated 12/1/2021 -…

    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 15 citations
  • Potential for harm · Dcited before2022-02-25 · 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

    Based on medical record review, observation, and interview the facility failed to ensure care and services were provided to maintain an indwelling urinary catheter for 1 of 1 resident (Resident #157) reviewed for catheters. The findings include: Review of the medical record, revealed Resident #157 was admitted to the facility with diagnoses of Acute and Chronic Respiratory Failure, Acute Kidney Failure, Chronic Kidney Disease, Seizures, Prostate Cancer, and Benign Prostatic Hypertrophy. Review of the Physician's Orders dated February 2022 revealed there was no order for an indwelling urinary catheter or catheter care. Review of the Treatment Administration Record (TAR) dated 2/2022, revealed there was no documentation Resident #157 received care for the indwelling urinary catheter. Observation in the resident's room on 2/23/2022 at 7:44 AM and 12:02 PM, and on 2/24/2022 at 12:11 PM, revealed Resident #157 had an indwelling urinary catheter. During a telephone interview on 2/25/2022 at 2:50 PM, the interim Minimum Data set (MDS) Coordinator confirmed Resident #157 should have 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-25 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure dental services were provided for 2 of 2 residents (Resident #11 and #24) reviewed for dental services. The findings include: Review of the facility's policy titled, Dental Examination/Assessment, dated 12/2013, revealed .Each resident shall undergo a dental assessment prior to or within ninety .days of admission . Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Blindness in the Right and Left Eye, Nontraumatic Intracerebral Hemorrhage, Depression, Anxiety Disorder, Dysphagia, Spastic Hemiplegia Left Side, and Diffuse Traumatic Brain Injury. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had moderate cognitive impairment, was dependent on staff for oral hygiene and had her own natural teeth. Medical record review revealed there was no documentation that Resident #11 had received a dental consult. Observation 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-12-11 · tag F0657 — failed to keep the care plan current — pattern
    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, observation, and interview, the facility failed to revise the careplan to reflect the current status for 6 of 27 (Resident #14, #23, #47, #57, #66, and #67) residents reviewed for activities, pressure ulcers, hospice, isolation, and indwelling urinary catheter. The findings include: 1. The facility's Activity Evaluation policy revised May 2013, documented, .In order to promote the physical, mental, and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident .The activity evaluation is used to develop an individual activities care plan . The facility's Palliative/End-of-Life Care-Clinical Protocol policy, revised July 2017, revealed .The interdisciplinary assessment of the resident and family is the basis of the individualized care plan. The assessment will include at least: .documentation of disease status, including diagnosis and prognosis .strengths; concerns, goals, and values of the resident and family;…

    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 · E2019-12-11 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    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 3 of 6 (Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #1 and #3) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 6 medication errors were observed out of 28 opportunities for error, resulting in a medication error rate of 21.42857143%. The findings include: 1. The facility's Administering Medications policy revised December 2012, documented, .Medications shall be administered in a safe and timely manner, and as prescribed .Medications must be administered in accordance with the orders .The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . 2. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses of Acute Respiratory Failure, Anemia,…

    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 · E2019-12-11 · tag F0761 — failed to label and store drugs safely — pattern
    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 stored properly and safely as evidenced by opened, undated, expired, and unsecured medications in 3 of 10 (First Floor Medication Cart, First Floor and Second Floor Treatment Cart, and Second Floor Medication Cart) medication storage areas. The findings include: 1. Review of the facility's Storage of Medications policy dated [DATE] documented, .If medication is not dated .If this exceeds manufactures expiration guidelines, facility must destroy .Compartments .containing drugs and biologicals shall be locked when not in use, and tray or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . 2. Observations in the First Floor Medication Cart on [DATE] at 1:14 PM, revealed 1 open and undated vial of Humulin 70/30 insulin and 1 open and undated vial of Lantus insulin. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 1:14 PM, at the First 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-12-11 · 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 practices to prevent the potential spread of infection were maintained for 1 of 2 (Resident #14) sampled residents reviewed for wound care, 1 of 8 (Resident #30) sampled residents reviewed with use of respiratory equipment, 1 of 7 (Resident #57) sampled residents reviewed for medication administration, and 1 of 12 (Resident #67) sampled residents reviewed with indwelling urinary catheters. The findings include: 1. The facility's Wound Care policy dated August 2019 documented, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Wash and dry your hands thoroughly .Wipe reusable supplies with alcohol as indicated ( .outsides of containers that were touched by unclean hands, scissor blades .) . The facility's Catheter Care, Urinary policy revised September 2014 documented, .Be sure the catheter tubing and drainage bag are kept off the floor . The facility's undated…

    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 · D2019-12-11 · tag F0569 — isolated
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, petty cash account review, and interview, the facility failed to provide a final accounting of the resident's funds to the resident's estate within 30 days after death for 1 of 1 (Resident #272) residents trust funds reviewed. The findings include: 1. The facility's undated admission Agreement policy documented, .Resident for services not used shall be refunded to the Resident within thirty (30) days after discharge provided final balances due for all charges have been paid in full .In the event of the Resident's death, all refund checks will be made out to the Resident's estate . 2. Medical record review revealed Resident # 272 was admitted to the facility on [DATE] with diagnoses of Atrial Fibrillation, Encephalopathy, Peripheral Vascular Disease, Gastroesophageal Reflux Disease, Parkinson's Disease, Dysphagia, and Major Depressive Disorder. The discharge Minimum Data Set (MDS) dated [DATE] documented, Death in facility. Review of the facility's Collierville Nursing and Rehabilitation…

    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 · D2019-12-11 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 provide an appropriate notice in writing to the resident and/or legal representative when skilled services were terminated for 1 of 3 (Resident #123) sampled residents reviewed. The findings include: 1. Medical record review revealed Resident #123 was admitted to the facility on [DATE] with diagnoses of Dementia, Ataxia, Dysphagia, Muscle Weakness, Encephalopathy, and Malnutrition. 2. The facility was unable to provide documentation that Resident #123 was notified that skilled services would be terminated prior to termination of the skilled services. 3. Interview with the Business Office Manager on 12/11/19 at 9:00 AM in the Business Office revealed an Advanced Beneficiary Notice policy was not available. 4. Interview with the Business Office Manager on 12/11/19 at 9:14 AM, in the Business Office, the Business Office Manager was asked when the Notice of Medicare Non-Coverage (NOMNC) was sent to Resident #123 or their responsible party to advise…

    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 before2019-12-11 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to follow the grievance policy for 1 of 8 (Resident #66) sampled residents. The findings include: 1. Review of the facility's Grievances/Complaints, Recording and Investigating policy revised April 2017, documented .The Grievance Officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log .The following information will be recorded and maintained in the log: a. The date the grievance/complaint was received; b. The name and room number of the resident filing the grievance/complaint .c. The name and relationship of the person filing the grievance/complaint on behalf of the resident .d. The date the alleged incident took place; e. The name of the person(s) investigating the incident; f. The date the resident, or interested party, was informed of the findings .g. The disposition of the grievance(i.e., resolved, dispute .The resident, or person acting on behalf of the resident, will be informed…

    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 before2019-12-11 · 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 policy review, medical record review, observation, and interview, the facility failed to provide oral hygiene for 1 of 2 (Resident #10) sampled residents reviewed for activities of daily living. The findings include: The facility's Mouth Care policy revised October 2010 documented, .The purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Cerebral Infarction, and Multiple Sclerosis. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had severely impaired cognition and was totally dependent on staff for all activities of daily living. Observation in Resident #10's room on 12/9/19 at 9:50 AM, 11:48 AM, and 1:40 PM, and on 12/10/19 at 8:43 AM, revealed Resident #10's teeth and inside of the mouth had thick white dried sputum and white dried…

    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 · D2019-12-11 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 individualized activities of interest for 1 of 2 (Resident #47) sampled residents reviewed for activities. The findings include: 1. The facility's Activity Evaluation policy with a revised date May 2013 documented, .In order to promote the physical, mental, and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident .The activity evaluation is used to develop an individual activities care plan (separate from or as part of the comprehensive care plan) .The completed activity evaluation will be part of the resident's medical record and shall be updated as necessary . 2. Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses of Respiratory Failure, History of Falling, Dysphagia, Tracheostomy, Dependence on Ventilator, Depression, Gastrostomy, Hypertension, and Atrial Fibrillation. Review of the 5 day Minimum Data Set (MDS) dated…

    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 before2019-12-11 · 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 medical record review, observation, and interview, the facility failed to provide physician's orders and a diagnosis for 2 of 2 (Resident #33 and #67) sampled residents reviewed for urinary catheter use. The findings include: 1. Medical Record review revealed Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Paraplegia, Sepsis, and Muscle Weakness. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was totally dependent on staff for toilet use, always incontinent of bowel, had an indwelling urinary catheter, and received antibiotics for 6 days. Review of the quarterly MDS dated [DATE] revealed Resident #33 had an indwelling urinary catheter and received antibiotics for 4 days. Medical record review revealed a physician's order for an indwelling urinary catheter dated 12/11/19. There was no physician's order for the indwelling urinary catheter prior to 12/11/19. Observations on 12/9/19 at 10:05 AM, 12:09 PM, 2:37 PM, and 4:39 PM, and 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-12-11 · 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 follow the physician's orders for enteral feedings for 1 of 2 (Resident #30) sampled residents reviewed with enteral feedings. The findings include: Medical record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses of Acute Respiratory Failure, Anemia, Pancreatitis, Diabetes, Gastrostomy Status, and Hypertension. Review if the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 had severe cognitive impairment, was totally dependent on staff for eating, and received 51 percent or more calories and 501 cubic centimeters (cc) or more fluids through a feeding tube. Review of a nutrition note dated 12/3/19 revealed the Registered Dietician (RD recommended to decrease the Glucerna 1.5 from a rate of 80 cc per hour to 70 cc per hour due to a gradual weight increase. Review of the Physician's Orders dated 12/5/19, revealed Resident #30 should receive Glucerna 1.5 at a rate of 70 cc per hour.…

    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 · D2019-12-11 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to act timely on pharmacy recommendation for 1 of 5 (Resident #19) sampled residents reviewed for unnecessary medications. The findings include: 1. The review of facility's Medication Regimen Reviews policy revised April 2007, documented .the Consultant Pharmacist performs medication regimen reviews (MRR) monthly and documents his findings and recommendations. The Consultant Pharmacist will provide a written report to physicians for each resident with an identified irregularity. The Consultant Pharmacist will provide the Director of Nursing Services (DON) and the Medical Director with a written, signed and dated copy of the report, listing the irregularities found and recommendations for their solutions . 2. Medical record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Dysphagia, Diabetes Mellitus, Kidney Disease, Anxiety, Dementia, Depression, Asthma,…

    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 · D2019-12-11 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to monitor behaviors and medication side effects for 1 of 5 (Resident #27) sampled residents reviewed for unnecessary medications. The findings include: 1. The facility's Antipsychotic Medication Use revised December 2016 documented, .The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others .Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending Physician .General/anticholinergic .Cardiovascular .Metabolic .Neurologic . 2. Medical record review revealed Resident #27 was admitted to the facility on [DATE], with diagnoses of Age Related Cognitive Decline, Anxiety, Dementia, Delusional Disorder, and Hypertension. The Physician's Orders dated 12/11/19 documented, .Mirtazapine [an antidepressant…

    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.

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.

Part of a chain

This home belongs to SIMCHA HYMAN & NAFTALI ZANZIPER — 79 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 →

RatingThis homeChain avg
Overall 2 of 52.6-0.6 vs chain
Health inspection 3 of 52.7+0.3 vs chain
Staffing 1 of 52.2-1.2 vs chain
Quality measures 4 of 53.4+0.6 vs chain
The other 78 homes this chain runs (chain average 2.6★, per CMS)
1 of 5Beavercreek Health And RehabBeavercreek, OH 1 of 5Bradford Heights Nursing & RehabilitationHopkinsville, KY 1 of 5Centerville Health And RehabDayton, OH 1 of 5Clayton Rehabilitation and Healthcare CenterClayton, NC 1 of 5Dade City Health And Rehabilitation CenterDade City, FL 1 of 5Englewood Health And RehabEnglewood, OH 1 of 5Fulton Nursing and Rehabilitation, LLCFulton, KY 1 of 5Gainesville Health and RehabilitationGainesville, FL 1 of 5Garden View Health And Rehabilitation CenterVero Beach, FL 1 of 5Hertford Rehabilitation and Healthcare CenterHertford, NC 1 of 5Longwood Health And Rehabilitation CenterLongwood, FL 1 of 5Lotus Village Center for Nursing and RehabilitatioSparta, NC 1 of 5Magnolia Creek Nursing And RehabilitationCovington, TN 1 of 5Mills Nursing & RehabilitationMayfield, KY 1 of 5Mountain Ridge Health and RehabilitationMonticello, KY 1 of 5Naples Health And Rehabilitation CenterNaples, FL 1 of 5Southpoint Rehabilitation and Healthcare CenterDurham, NC 1 of 5Spring View Nursing & RehabilitationLeitchfield, KY 1 of 5Sunrise Point Health And Rehabilitation CenterRockledge, FL 1 of 5Windsor Rehabilitation and Healthcare CenterWindsor, NC 1 of 5Winter Park Care And RehabilitationWinter Park, FL 1 of 5Xenia Health And RehabXenia, OH 2 of 5Accordius Health at Rose Manor LLCDurham, NC 2 of 5Barren County Nursing and RehabilitationGlasgow, KY 2 of 5Bellbrook Health And RehabBellbrook, OH 2 of 5Cherokee Park RehabilitationLouisville, KY 2 of 5Clinton PlaceClinton, KY 2 of 5Eden Rehabilitation and Healthcare CenterEden, NC 2 of 5Fairpark Health And RehabilitationMaryville, TN 2 of 5Glenview Health and RehabilitationGlasgow, KY 2 of 5Green Acres HealthcareMayfield, KY 2 of 5Jamestown Place Health And RehabJamestown, OH 2 of 5Lilac At Bayview, TheSaint Augustine, FL 2 of 5Madisonville Health and Rehabilitation, LLCMadisonville, KY 2 of 5Midtown Center For Health And RehabilitationMemphis, TN 2 of 5Pelican Health at CharlotteCharlotte, NC 2 of 5River Grove Health And RehabilitationLoudon, TN 2 of 5Stonecreek Health and RehabilitationPaducah, KY 2 of 5Sycamore Heights Health and RehabilitationLouisville, KY 2 of 5Venice Health And Rehabilitation CenterVenice, FL

Showing 40 of 78; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
COLLIERVILLE NURSING AND REHABILITATION LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 10/13/2018
HYMAN, SIMCHAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST50%since 10/13/2018
MOUGHRABIEH, MOHAMADIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2022
CLEARVIEW HEALTHCARE MANAGEMENT TN LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/23/2026
CROWDUS, KENNETHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/09/2026
VUJANOVIC, MICKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/12/2018

CMS files one row per role, so the 11 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$8.5M
Net patient revenuemost recent cost report
-8.5%
Operating marginrevenue minus expenses
$2.4M
Related-party expense26% of expenses
Who pays — share of resident-days
Medicaid 67%Medicare 9%Other / private 24%

This home reported $2.4M paid to related parties — landlords or management companies under common ownership — equal to about 26% 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

$345per resident / day
operating cost
$10,483per month
≈ monthly operating cost
$318per 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 445495. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-10, 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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