Magnolia Creek Nursing And Rehabilitation

Location & what’s nearby

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

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

37.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 101 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 156 beds and averages 89.6 residents a day — about 57% occupied, or roughly 66 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 3.30 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 1.61 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 2.96 hrs/resident/day on weekends vs 3.44 on weekdays — 14% thinner on weekends. RN hours go from 0.50 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

28 citations, most serious first. The 13 most serious are shown; the remaining 15 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-08-12 · 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 facility policy review, ANA's [American Nurses Association] Principles for Nursing Documentation, review, job description review, medical record review, Neuro (Neurological) Check Assessment Form review, and interviews the facility failed to ensure treatment and care was provided in accordance with professional standards of practice, the comprehensive care plan and the resident's goals for care. The facility failed to promptly identify and intervene for an acute change in condition for 1 of 3 (Resident #1) sampled residents reviewed for quality of care. The facility's failure to ensure a resident received appropriate assessments and interventions resulted in Immediate Jeopardy when on [DATE] Resident #1 was noted to have a raised area on his left forehead. Nursing staff notified the contracted telehealth provider and failed to give complete, relevant, and accurate information resulting in Resident #1 remaining in the facility for 7 hours and 36 minutes before being transferred to the emergency room for…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2021-12-09 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to revise the Care Plan to reflect the residents' current status for 3 of 27 sampled residents (Resident #11, #20, and #56). The facility's failure to revise the Care Plan with appropriate interventions resulted in actual harm when Resident #56 sustained a fall which resulted in a fracture (broken bone) to the left femur (large upper bone in the leg). Findings include: Review of the facility's policy titled, Falls Management Program Guidelines, dated 12/1/2018, revealed .Should the Resident experience a fall the attending nurse shall complete a post fall assessment. This includes .interventions to reduce the risk of repeat episodes and a review by the IDT [Interdisciplinary Team] to evaluate thoroughness of the investigation and appropriateness of the interventions .The care plan should be updated to reflect, any new or change in interventions . Review of the facility's undated policy titled, Care Planning -…

  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
• Actual harm · Gcited before2021-12-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to implement appropriate interventions to prevent falls and injury for 1 of 7 sampled residents (Resident #56) reviewed for accidents. The facility's failure to provide appropriate interventions resulted in actual harm when Resident #56 sustained a fall which resulted in a fracture (broken bone) of the left femur (large upper bone of the leg). The findings include: Review of the facility's policy titled, Falls Management Program Guidelines, dated 12/1/2018, revealed .strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measure .recognizes even the most vigilant efforts may not prevent all falls and injuries. In those cases, intensive efforts will be directed toward minimizing or preventing injury .DEFINITION: A fall is considered to be .an unintentionally coming to rest on the ground, floor, or lower level, but not as a result of an overwhelming external force .An episode…

  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 before2025-09-17 · 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, medical record review, review of the resident trust accounts, and interview, the facility failed to refund the resident's funds within 30 days of death or discharge for 1 of 1 (Resident #103) sampled residents reviewed for personal fund account statements. The findings include: 1. Review of the undated facility policy titled, .Conveyance of Funds Upon a Resident's Death., revealed .Purpose.To ensure conveyance of funds upon a resident's death are consistent with applicable legal requirements and standards of practice.Within thirty (30) days of the death of the resident, the company will convey the deceased resident's personal funds and a final accounting of those funds to the individual or probate jurisdiction administering the resident's estate. 2. Review of the medical record revealed Resident #103 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Diabetes Mellitus, and Dysphagia (difficulty swallowing foods or liquids). Review of the significant…

  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 before2025-09-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure the environment was free from accident hazards when unsecured sharps were in 1 of 46 (Resident #5 and #20) sampled residents' bathrooms and failed to complete fall assessment documentation for 1 of 3 (Resident #10) residents sampled for falls. The findings include: 1. Review of the facility policy titled, Accidents and Supervision, dated 6/1/2025, revealed .resident environment will remain as free of accident hazards.Environment refers to any environment or area in the facility that is frequented by or accessible to the residents, including (but not limited to) the residents' rooms, bathrooms.Hazards refers to elements of the resident environment that have the potential to cause injury. Review of the facility policy titled, Falls, dated 6/2025, revealed .Falls Management Program Guidelines .Should the Resident experience a fall the attending nurse shall complete a post fall assessment . 2. Review of the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-17 · 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 record review, observation, and interview, the facility failed to provide appropriate treatment and services when staff failed to follow physician's orders for 1 of 2 (Resident #10) sampled residents reviewed for urinary tract infections (UTIs). The findings included: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Dementia, Chronic Kidney Disease, Diabetes, and Schizophrenia. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #10 was moderately cognitively impaired. Review of the progress notes dated 9/9/2025, revealed .Resident [Resident #10] c/o [complains of] of burning when urinating, this nurse spoke to NP [Nurse Practitioner] about residents concern. NP ordered urine culture. Resident .temp. [temperature] 98.3. RP [Responsible Party] notified and agrees . Review of the Physician's Orders dated 9/9/2025, revealed…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-17 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  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 staff were accurately administering medications per Physician's Orders and to meet professional standards of practice for 2 of 5 (Residents #38 and #64) residents reviewed for unnecessary medications. The findings include: 1. Review of the facility policy titled Medication Administration, dated 2/20/2024, revealed Medications are administered .as ordered by the physician .compare the medication .to the MAR [Medication Administration Record] to verify .medication dose . 2. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE], with diagnoses including Anemia, Diabetes, and Arthritis due to other bacteria, unspecified joint. Review of the Physician Order Report dated 8/17/2025-9/17/2025, revealed .micafungin [antifungal] 100 mg [milligrams] . Review of the View Prescription Order, dated 9/10/2025, revealed Micafungin .Pharmacy Directions .INFUSE 100ML [milliliters] (100 MG DOSE) .OVER 60…

  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 · Dcited before2025-09-17 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored when expired medications were found in 1 of 9 (Medication Cart #3) medication storage areas. The findings include: 1. Review of the facility policy titled, Medication Storage, dated 2/2/2025, revealed .It is the facility policy to ensure all medications .will be stored in accordance to the manufacturer's recommendations.All drugs and biologicals will be stored in locked compartments.under proper temperature controls. 2. During an observation and interview at Medication Cart #3 on 9/17/2025 at 7:40 AM, revealed 5 unopened foil packs of Ipratropium (used to help breathing) 0.2 percent (%) with 5 vials in each pack with an expiration date of 7/2025. Registered Nurse (RN) B confirmed expired medication should not be in the medication cart. During an interview on 9/17/2025 at 8:17 AM, the DON confirmed expired medications should not be on the medication cart.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-17 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 2 of 5 nurses (Registered Nurse (RN) A and RN D) failed to disinfect reusable resident equipment for 2 of 8 (Resident #82 and #85) residents observed and when 2 of 5 nurses (RN D and Licensed Practical Nurse (LPN) F) failed to perform hand hygiene during medication administration. The findings include: 1. Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Equipment, revealed .Reusable resident-care equipment .Reusable multiple-resident items .are items that may be used multiple times for multiple residents. Examples include stethoscopes, blood pressure cuffs .Multiple-resident used equipment shall be cleaned and disinfected after each use . Review of the facility policy titled, Medication Administration, dated 2/2024, revealed .Wash hands prior to administering medication . Review of the facility policy…

  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 before2025-09-17 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  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 a safe and functional environment when toilets were not securely fastened to the floor in 4 of 46 occupied resident's bathrooms affecting 6 of 94 (Resident #5, #20, #29, #54, #61, #78) residents. The findings include: 1. Review of the facility policy titled, Safe and Homelike Environment, dated 6/1/2025, revealed .the facility will provide a safe, clean, comfortable and homelike environment.ensuring that the resident can receive care and services safely.maximizes resident independence and does not pose a safety risk. 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Diabetes, Bipolar Disorder, Depression, and Pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #5 was cognitively intact. Resident #5 required supervision 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-12 · 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 facility policy review, signed Job Description review, medical record review, and interview, the facility failed to ensure an injury of unknown origin was reported to the State Survey Agency (SSA) for 1 of 10 (Resident #1) sampled residents reviewed for abuse. The facility also failed to report the results of a thorough investigation for abuse within 5 working days to the SSA. The findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation, revised 5/2025, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect.Abuse.includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-12 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the facility policy review, signed Job Description review, medical record review, and interview, the facility failed to investigate an injury of unknown origin for 1 of 10 (Resident #1) sampled residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation with a revision date of 5/2025, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect.Abuse.includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.The facility will develop and implement written policies and procedures .to investigate any such allegations; and .Include training for new and existing staff on activities that constitute abuse .reporting procedures, and dementia management .Training topics will…

  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 · D2025-08-12 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 the American Nurses Association (ANA)'s Principles for Nursing Documentation review, facility policy review, medical record review, and interview, the facility failed to ensure medical records were complete and accurately documented for 1 of 7 (Resident #1) sampled residents reviewed. The findings include: Review of the ANA's Principles for Nursing Documentation dated 2010, revealed .Nurses document their work and outcomes for a number of reasons: the most important is for the communicating within the health care team .Nurses and other health care providers aim to share information about patients and organizational functions that is accurate, timely, contemporaneous, concise, thorough, organized, and confidential .Foremost of such electronic documentation is the electronic health record (EHR), provides an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$16,985 in federal fines across 1 penalty.

• $16,985 — penalty dated 2025-08-12

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

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 →

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

Who owns this facility

CMS files one row per role, so the 8 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.8M paid to related parties — landlords or management companies under common ownership — equal to about 36% 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

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