Magnolia Healthcare And Rehabilitation Center
1410 Trotwood Avenue, Columbia, TN 38401 · For profit - Limited Liability company · 181 certified beds · (931) 388-6443 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- 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
- a high number of inspection citations overall (18) — 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)
- nursing-staff turnover (72%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 18.0% | 14.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.4% | 6.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.3% | 1.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 44.1% | 13.8% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 6.1% | 3.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 8.5% | 17.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 34.2% | 31.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.5% | 5.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 21.7% | 20.0% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.9% | 16.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.7% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 56.4% | 79.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 27.8% | 22.6% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.9% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.64 | 1.67 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.13 | 1.56 | 1.80 | worse |
‡ 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.
48.2% 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 50 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 59.5% 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 42 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 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 48.2%CMS range 35.5–59.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 6.6–14.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 59.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 69.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 26.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.2% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.6%CMS range 5.5–14.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.06 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 181 beds and averages 81.8 residents a day — about 45% occupied, or roughly 99 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.40 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.33 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 2.87 hrs/resident/day on weekends vs 3.61 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.37 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 72% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.
- Potential for harm · Dcited before2026-04-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 facility policy review, medical record review, observation and interview the facility failed to ensure the environment was free from accident hazards when sharps were found unattended and unsecured in the shared room of 2 of 82 (Residents #30 and #65) sampled residents observed. 1. Review of the facility's policy titled, Regulated [Biohazard] Medical Waste, dated 6/11/2025, revealed .It is the policy of this facility to ensure that regulated medical waste is managed, handled, stored, and transported as per Federal, State, and local guidance and regulations.Examples of regulated medical waste include.sharp items.Contaminated sharps will be placed in appropriate sharps containers located at the point of use. 2. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, Depression, and Hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #30 scored 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.
- Potential for harm · Dcited before2026-04-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to ensure staff obtained daily weights for 1 of 6 (Resident #16) sampled residents reviewed for nutrition. The findings include: 1. Review of the facility policy titled, Medication Administration, dated 4/9/2025, revealed .obtain and record vital signs.per physician orders. 2. Review of the medical record revealed Resident #16 was readmitted to the facility on [DATE], with diagnoses including Hemiplegia, Adult Failure to Thrive, and Abnormal Weight Loss. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired. Review of the Physician's Order dated 1/29/2026, revealed .Weigh patient daily at 0600 [6:00 AM] in the morning. Review of the Medication Administration Record (MAR) dated January 2026, revealed daily weights were not obtained as ordered by the physician 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.
- Potential for harm · Dcited before2026-04-01 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 facility policy review, medical record review, observation, and interview, the facility failed to ensure medication was properly stored in 1 of 2 (South Short Hall) medication rooms and in 2 of 82 (Resident #8 and #24) sampled residents' rooms. The findings include: 1. Review of the facility policy titled, Medication Storage, dated 3/31/2025, revealed .It is the policy of this facility to ensure all medications housed on our premise will be stored.All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms).back -up stock of Schedule III, IV and V medications are stored under double-lock and key. 2. Observation and interview in the Medication Room on the South Short Hall on 4/1/2026 at 8:48 AM, revealed 1 open and 2 unopen vials of Lorazepam (a Schedule IV controlled substance medication used to treat anxiety) 20 mg [milligram]/10 ml [milliliter] in a clear unlocked/unsecured box in the refrigerator. Licensed Practical Nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-01 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation, and interview, the facility failed to ensure food was stored and prepared under sanitary conditions when unlabeled, undated, and expired food items were found stored, an empty soap dispenser was observed at the hand washing station, the inside of the microwave was splattered with dried food particles, the deep fryer had brown oil with food particles floating in it, there was a black build up on the floor, there was dried food particles on a metal pan, a layer of dust on a shelf of the drying rack, and the warming oven had a build up inside the doors. The facility had a census of 82 and 79 of the residents were served from the Kitchen. The findings include: Review of the facility policy titled, Food Safety Requirements, dated 3/26/2025, revealed .Food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety.Food safety practices shall be followed throughout the facility's entire food handling…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-01 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, and interview, the facility failed to maintain the prevention and spread of infection during wound care, catheter care, and with Enhanced Barrier Precautions for 2 of 4 (Resident #16 and #24) sampled residents reviewed. The findings include: 1. Review of the facility policy titled, Infection Control Policy and Procedure, dated 2026, revealed .Require staff to follow hand hygiene practices consistent with accepted standards of practice.CMS [Centers for Medicare & Medicaid Services] recommends specialized training include the following.Principles of standard precautions.hand hygiene.use and care of indwelling urinary.catheters.wound management.The Facility shall develop and implement written policies and procedures for the provision of infection prevention and control.The use and care of urinary catheters.Wound care.Knowledge and skills pertaining to the IPSP's [Infection Prevention and Control Program] standards, policies and procedures are needed by all staff in order to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-06-15 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 the Centers for Disease Control and Prevention (CDC) guidelines, policy review, review of Employee Screening logs, employee time sheets and agency invoices, observation, and interview, the facility failed to ensure practices to maintain the spread of infection were maintained when 14 of 67 staff members (Licensed Practical Nurse (LPN) #1, Agency LPN #1, #2, #3, and #4, Certified Nursing Assistant (CNA) #1, #2, and #3, Agency CNA #1, #2, #4, #5 and #6, and Dietary Aide #1) failed to complete screening for the prevention and detection of COVID-19 prior to working on 3 of 3 days (5/28/2022, 5/29/2022 and 6/4/2022) reviewed and when 3 of 4 nurses (Registered Nurse (RN) #1, Agency LPN #5, and #6) failed to perform hand hygiene for 4 of 5 sampled residents (Resident #7, #34, #35, and #375) observed during medication administration. This had the potential to affect the 76 residents residing in the facility. The findings include: Review of the CDC document titled, Interim Infection Prevention and Control…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-06-15 · tag F0553 — failed to let residents help plan their care — patternAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, review of the interdisciplinary Care Plan meeting sign in sheets, medical record review, and interview, the facility failed to ensure residents were involved in developing the Care Plan and making decisions about his or her care and failed to include direct care staff in the Interdisciplinary Care Planning for 3 of 3 sampled residents (Residents #20, #35, and #65) reviewed for Care Plan meetings. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 4/2022, revealed .the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .The IDT may include .Attending Physician .registered nurse who has responsibility for the resident .nurse aide who had responsibility for the resident .member of food and nutrition services .Social Services staff member .Therapy services staff members .resident and the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-06-15 · tag F0578 — failed to honor advance directives / code status — patternHonor 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 Advanced Directive for 16 of 27 sampled residents (Resident #7, #8, #13, #15, #19, #20, #21, #26, #28, #32, #35, #37, #47, #53, #56, and #65) reviewed for Advanced Directives. The findings include: Review of facility's undated policy titled, Resident Rights and Responsibilities, revealed .all Residents have the right to participate in their health care decisions and to make Advance Directives .and [Named Facility] respects and upholds those rights . Review of the medical record, revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Rheumatoid Arthritis, Alzheimer's Disease, Schizophrenia, and Depression. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #7 had a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Review of Resident #7's medical record, revealed there…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-06-15 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to accurately assess the nutritional status and to follow the facility's policy for monitoring weights for 6 of 6 sampled residents (Resident #19, #28, #42, #57, #375, #376) reviewed for nutrition. The findings include: Review of the facility's policy titled, Nutritional Assessment, revised 10/2017, revealed .The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission .and as indicated by a change in condition that places the resident at risk for impaired nutrition .As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition . Review of the facility's policy titled, Weight Management, revised 8/2021, revealed .residents that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-06-15 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to ensure 6 of 16 sampled residents (Resident #13, #28, #42, #52, #56, and #376) had alternative food and menu choices. The findings include: Review of the facility's undated policy titled, .RESIDENT RIGHTS AND RESPONSIBILITIES, revealed .Recognize each resident's individuality and provide services in a person-centered manner .promotes .resident's quality of life . Review of the facility's undated policy titled, RESIDENT FOOD PREFERENCES, revealed .Dietary Manager, or designee with regards to obtaining food preferences and conducting an initial visit to the resident .this visit should occur within 72 hours from admission date .important that these preferences .be honored . Review of the medical record, revealed Resident #13 was admitted to the facility on [DATE] with diagnoses of Osteoarthritis, Gastroparesis, Nausea, and Morbid Obesity. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #13 had a Brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 8 citations
- Potential for harm · D2022-06-15 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 develop a Baseline Care Plan within 48 hours of admission that included the initial goals and needs for 3 of 19 sampled residents (Resident #42, #57 and #75) reviewed. The findings include: Review of the medical record, revealed Resident #42 was admitted on [DATE] with diagnoses of Diabetes, Bipolar Disorder, and Cellulitis. Review of the medical record, revealed Resident #42 did not have a Baseline Care Plan developed within 48 hours of admission that addressed the initial goals and needs of the resident. A Comprehensive Care Plan was initiated on 5/11/2022. During an interview on 6/15/2022 at 4:11 PM, the Minimum Data Set (MDS) Coordinator confirmed Resident #42 did not have a Baseline Care Plan completed within 48 hours of admission. Review of the medical record, revealed Resident #57 was admitted on [DATE] with diagnoses of Hypertension, Peripheral Vascular Disease, Atherosclerosis, Dementia, Septicemia, and Anxiety. Review of the medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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, observation, and interview, the facility failed to ensure medications were administered as ordered for 2 of 2 sampled residents (Resident #47 and #65) reviewed. The findings include: Review of the facility's undated policy titled, MEDICATION ADMINISTRATION Missed Medication Dose, revealed .Licensed nurse is to administer medications per physicians order. If a medication is not administered at the prescribed time due .the nurse will notify the physician or physical extender of the missed dose or possible need to change the medication administration time .Physician .to determine if further monitoring or an alternative therapy is required . Review of the medical record, revealed Resident #47 was admitted to the facility on [DATE] with diagnoses of Depression, Fibromyalgia, and Chronic Obstructive Pulmonary Disease. Review of the facility's Medication Administration Record (MAR) dated 6/2022, revealed an order for .Hibiclens Liquid [an antiseptic that fights bacteria]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure Care Plan interventions were followed to prevent falls for 1 of 1 sampled resident (Resident #20) reviewed for falls. The findings include: Review of the facility's policy titled, FALL PREVENTION AND MANAGEMENT, revised 10/2021, revealed .All residents will be assessed for risk of falling using the 'Long Term Care Fall Risk Assessment Form' .The assessment will be competed up on admission, quarterly, annually, and/or if a change in condition requiring completion of a new MDS [Minimum Data Set] .Interventions appropriate to individual resident and their risk for falls will be implemented based on recognized standards of practice . Review of the medical record, revealed Resident #20 was admitted to the facility on [DATE] with diagnoses of Intracerebral Hemorrhage, Falls, Diabetes, and Obesity. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #20 had a Brief Interview for Mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2019-08-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by the absence of hand washing supplies, improper handwashing, undated, unlabeled, and expired food items, carbon build up on pans and the stove, lack of hair restraints, dirty oven doors, dirty kitchen floor, improper storage of an ice scoop, black build up on the seal of the milk cooler, a dirty drip pan, a dirty deep fat fryer, potatoes contaminated with an alcohol preparation (prep) pad package, improper cleaning of a thermometer, unsealed food items, incomplete dishmachine temperature logs, improper storage of glasses, and improper handling of tongs. The facility had a census of 73 residents with 72 of those residents receiving a tray from the kitchen. The findings include: 1. The facility's HANDWASHING AND GLOVE USE policy revised 2/1/14 documented, .Handwashing is a priority for infection control .When gloves are used, handwashing must occur .prior to putting on gloves and whenever gloves are changed The facility's FOOD…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-08-01 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to ensure the patient representative was involved in developing the care plan and making decisions and failed to revise the care plan for 2 of 20 (Resident #7 and #26) sampled residents reviewed. The findings include: 1. The facility's Care Plan, Comprehensive Person-Centered policy revised 2016 documented, .The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .The IDT includes .the resident's legal representative .Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's conditions change . 2. Medical Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Paranoid Schizophrenia, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Parkinson's Disease, Dementia, and Psychotic Disorder…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-08-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 the chemical safety chart, observation and interview, the facility failed to ensure the environment was free of accident hazards as evidenced by an aerosol can and an unsecured razor in 1 of 51 (room [ROOM NUMBER]) resident rooms. The finding include: 1. The facility's CHEMICAL SAFETY CHART revised 3/5/19 documented, .Aerosols .These cans can start a fire . 2. Observations in room [ROOM NUMBER] on 7/29/19 at 11:27 AM, revealed an aerosol spray can sitting on the shelf in the bathroom. Observations in room [ROOM NUMBER] on 7/30/19 at 7:40 AM, 8:57 AM, and 1:35 PM, and on 7/31/19 at 7:50 AM, 8:50 AM, and 9:45 AM, revealed an aerosol spray can and 1 razor sitting on the shelf in the bathroom. Interview with Licensed Practical Nurse (LPN) #2 on 7/31/19 at 9:45 AM, in the bathroom of room [ROOM NUMBER], LPN #2 confirmed the aerosol spray can and razor were sitting on the shelf. Interview with the Director of Nursing (DON) on 7/31/19 at 2:40 PM, in the Conference Room, the DON was asked if an aerosol spray…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-08-01 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 — the official record, unedited, may be distressing
Based on policy review, observation, and interview, the facility failed to ensure medications were stored properly and safely in 1 of 6 (South Long Hall Medication Cart 1) medication storage areas. The findings include: 1. Review of the facility's undated Storage of Medications policy documented, .Medication rooms, carts and medication supplies are locked when not attended . 2. Observations on the South Long Hall on 7/30/19 at 8:50 AM and 9:25 AM, revealed the Medication Cart 1 was unlocked and unattended. 3. Interview with the Director of Nursing (DON) on 7/31/19 at 2:56 PM, in the Conference Room, the DON was asked if a medication cart should be unlocked and unattended. The DON stated, .No .
- Potential for harm · Dcited before2019-08-01 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to ensure measures to prevent the potential spread of infection were followed by 1 of 1 (Licensed Practical Nurse (LPN) #1)nurses observed during wound care observations. The findings include: 1. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses of Unstageable Pressure Ulcer of the Sacral Region, Cerebrovascular Accident, Neuromuscular Dysfunction of the Bladder, Pressure Ulcer of the Left Heel, Aphasia, and Hypertension. Observations in Resident #26's room on 7/31/19 at 10:30 AM, revealed LPN #1 performed wound care to Resident #26's Stage 4 pressure wound. LPN #1 removed a pair of scissors from her pocket and placed them on the over bed table, without cleaning the scissors, then used the scissors to cut the clean wound dressing six different times, without cleaning the scissors. LPN #1 touched the inside of the trash bag containing the soiled dressing with her gloves and continued to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| COLUMBIA TN HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/01/2018 |
| GOLD RIVER HOLDINGS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/01/2018 |
| SCHERM ESTATE LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/01/2018 |
| LEFKOWITZ, SHIMON | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/01/2018 |
| NUSSBAUM, MATTISYAHU | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | NO PERCENTAGE PROVIDED | since 05/01/2018 |
| SCHERMAN, AVI | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/01/2018 |
| WEINSTOCK, JEROME | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | NO PERCENTAGE PROVIDED | since 05/01/2018 |
| CIBC BANK USA | Organization | 5% OR GREATER SECURITY INTEREST | — | since 05/01/2018 |
| HARBOUR, CRYSTAL | Individual | W-2 MANAGING EMPLOYEE | — | since 05/01/2018 |
| KING, COURTNEY | Individual | W-2 MANAGING EMPLOYEE | — | since 05/01/2018 |
CMS files one row per role, so the 12 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
4 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.
This home reported $1.0M 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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Tennessee Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 445465. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-01, 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.