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Erwin Health Care Center

100 Stalling Lane, Erwin, TN 37650 · For profit - Individual · 125 certified beds · (423) 743-4131 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0604) — cited May 20242 immediate-jeopardy citations$10,024 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0604), cited May 2024
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,024 in federal fines (most recent 2024-05-17)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)

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

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

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

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
800 S Mohawk Dr · (423) 330-6177 · Call to confirm hours
Pharmacy
101 S Main Ave · (423) 743-4881 · Call to confirm hours
Grocery
1609 Jackson Love Hwy · (423) 743-6971 · Call to confirm hours
Park
Rock Creek Rd · Typically dawn to dusk
Place of worship
1313 Chestoa Pike · (423) 735-7795

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 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased17.7%14.0%15.4%worse
Long-stay residents who lose too much weight9.3%6.1%5.4%worse
Long-stay residents with a catheter left in their bladder0.8%0.7%0.9%better
Long-stay residents with a urinary tract infection1.1%1.8%2.0%better
Long-stay residents with depressive symptoms1.5%13.8%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury8.3%3.4%3.3%worse
Long-stay residents whose ability to walk worsened15.5%17.2%16.1%typical
Long-stay residents on antianxiety or hypnotic medication56.5%31.7%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers4.7%5.0%4.7%typical
Long-stay residents with worsening bladder/bowel control24.6%20.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table27.9%16.8%17.1%worse
Short-stay residents rehospitalized after admission5.4%22.6%22.6%better
Short-stay residents with an outpatient ER visit8.9%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days1.111.671.67better
Long-stay outpatient ER visits per 1,000 resident days0.931.561.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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

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

33.0% 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 43 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

33.0%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
5.0%U.S. median 56.6%
Met the expected recovery
0.16U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 5.0% 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 20 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 0.16 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF33.0%CMS range 19.3–47.851.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 6.7–15.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge5.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge5.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge5.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay4.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened8.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.0%CMS range 2.7–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.381.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.80
RN hours/ resident / day
0.63
LPN hours/ resident / day
1.97
Aide hours/ resident / day
3.40
Total nurse hours/ resident / day
0.64
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 125 beds and averages 71.8 residents a day — about 57% occupied, or roughly 53 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 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 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 2.94 hrs/resident/day on weekends vs 3.59 on weekdays — 18% thinner on weekends. RN hours go from 0.86 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

4
deficiencies at the latest standard inspection (2025-03-19)
6
at the previous standard inspection (2022-01-20)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

22 citations, most serious first. The 12 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2024-05-17 · tag F0604 — failed to not use physical restraints improperly — pattern
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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, review of facility documentation, medical record review, observation, and interview, the facility failed to recognize and use the least restrictive interventions or restraint device for the least amount of time and failed to attempt a reduction to a least restrictive device or eliminate the restraint devices during the 30-day assessments. The facility's failure to recognize and use the least restrictive interventions or restraint device for the least amount of time and failure to attempt a reduction to a least restrictive device or eliminate the restraint devices during the 30-day assessments resulted in 4 residents of 29 residents (Residents #9, #13, #18, and #21) being placed in restraints that were not the least restrictive for an extended amount of time. The findings include: Review of the facility's undated policy titled, POLICY AND PROCEDURE FOR RESTRAINTS AND SAFETY DEVICES, showed .Facility will use the least restrictive safety device or restraint to ensure safety 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · K2024-05-17 · tag F0835 — failed to run the facility competently — pattern
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, review of facility documentation, medical record review, observation, and interview, the facility failed to recognize and use the least restrictive interventions or restraint device for the least amount of time and failed to attempt a reduction to a least restrictive device or eliminate the restraint devices during the 30-day assessments. The facility's failure to recognize and use the least restrictive interventions or restraint device for the least amount of time and failure to attempt a reduction to a least restrictive device or eliminate the restraint devices during the 30-day assessments resulted in 4 of 29 sampled residents (Resident #9, #13, #18, and #21) being placed in restraints that were not the least restrictive for an extended amount of time. The findings include: Review of the facility's undated policy titled, POLICY AND PROCEDURE FOR RESTRAINTS AND SAFETY DEVICES showed .Facility will use the least restrictive safety device or restraint to ensure safety 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-19 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, and interviews the facility failed to ensure 1 resident (Resident #322) of 9 residents were treated with dignity during the lunch meal service when residents at the same table were not served the meal at the same time. The findings include: Review of the medical record revealed Resident #322 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Dementia, and Psychotic Disorder. Review of the comprehensive care plan for Resident #322 dated 2/28/2025, revealed .Self-Care Deficit .Feeding .Provide assistance with ADLs [activities of daily living] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #322 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment which indicated severe cognitive impairment. Further review revealed the resident was dependent upon staff assistance with eating. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses…

    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 before2025-03-19 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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 implement a person-centered care plan related to vision impairment for 1 resident (Resident #68) of 19 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Comprehensive Care Plan Procedures, dated 2/2/2024, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan .for each resident .to meet a resident's medical .nursing .needs and all services that are identified in the residents' comprehensive assessment . Review of the medical record revealed Resident #68 was admitted to the facility on [DATE] with diagnoses including Dementia, Glaucoma, and Need for Personal Care. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #68 scored a 5 on the Brief Interview for Mental Status (BIMS) assessment which indicated severe cognitive impairment. Further review revealed the resident had…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-19 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, observations, and interviews, the facility failed to ensure garbage and refuse were properly contained in 1 of 2 dumpsters (dumpster A) and failed to ensure the outside dumpster area was maintained in a sanitary and orderly condition. The findings include: Review of the facility's policy titled, Disposal of Garbage and Refuse, dated 12/20/2024, revealed .refuse containers and dumpsters kept outside the facility shall .have tightly fitting lids, doors, or covers .surrounding area shall be kept clean so that accumulation of debris .are minimized .garbage should not accumulate or be left outside the dumpster . During an observation of the outside dumpster area and interview on 3/17/2025 at 12:15 PM, with the Certified Dietary Manager (CDM), revealed 2 dumpsters for waste disposal. Further observation revealed dumpster A's front right sliding door was propped open which exposed the dumpster's contents to potential pests and the elements. Continued observation of the area behind dumpster A revealed 1 broken wooden chair, 9 broken wooden pallets (wet and…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-19 · 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 facility policy review, observation, and interview, the facility failed to offer hand hygiene assistance prior to meals for 2 residents (Residents #53 and #25) of 9 residents observed in the secure unit dining room. The findings include: Review of the facility's policy titled, Meal Supervision and Assistance, dated 12/20/2024, revealed .Be sure the resident's hands are washed before and after he or she has started .finished the meal . Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including Dementia, Cognitive Communication Deficit, and Need for Assistance with Personal Care. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #53 scored a 1 on the Brief Interview for Mental Status (BIMS) assessment which indicated severe cognitive impairment. Further review revealed the resident required substantial/ maximal assistance with personal hygiene. Review of the comprehensive care plan for Resident #53 revised…

    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 · Fcited before2022-01-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, observation, and interview, the facility failed to maintain a clean environment in the dietary department with the potential to affect 81 of 81 residents in the facility. The findings include: Review of the facility policy titled, Cleaning and Sanitization in Dietary, dated 5/2021 showed The food service area shall be maintained in a clean and sanitary manner .All equipment, food contact surfaces .shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized .Manual washing and sanitizing will employ a three-step process .Scrape food particles and wash using hot water and detergent .Rinse with hot water to remove soap residue .Sanitize with hot water or chemical sanitizing solution . Review of facility log titled Cleaning Deep Fryer showed the last entry documented for cleaning of the deep fryer was 1/11/2022. During the initial kitchen observation and interview on 1/18/2022 at 10:50 AM, with the Certified Dietary Manager (CDM), the deep fryer had brown food debris present in the oil and 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-01-20 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of Quality Assurance Performance Improvement (QAPI) Plan of Correction, medical record review, review of facility documentation, and interview, the facility failed to ensure the Quality Improvement Committee identified issues and implemented corrective action plans with monitoring to ensure care plans were continuously updated and current to meet the resident's needs and to ensure equipment in the kitchen was sanitary for use to prepare resident meals. The facility's failure had the potential to effect 81 of 81 residents in the facility. The findings include: Review of facility's policy titled, MDS [Minimum Data Set] and Care Plan (Person Centered Care Plan) dated 5/2021, revealed .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .care plans should be person centered, and unique for the residents' specific needs Quarterly care plans are updated during the MDS lookback period and up 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-20 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to complete a significant change assessment for 1 resident (Resident #17) of 18 residents reviewed for assessments. The findings include: Review of CMS's RAI Version 3.0 Manual Chapter 2 dated 10/2019 revealed .Guidelines to Assist in Deciding If a Change Is Significant or Not .Any decline in an ADL [Activity of Daily Living] physical functioning area where a resident is newly coded as Extensive assistance .since last assessment .Resident begins to use a restraint of any type when it was not used before . Resident #17 was admitted to the facility on [DATE] with diagnoses including Hypertension, Hip Replacement, and Alzheimer's Disease. Record review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #17 had severe cognitive impairment, required supervision with set up help for bed mobility, walking…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-01-20 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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, review of facility documents, observation, and interviews, the facility failed to provide a comprehensive care plan to address a potential environmental hazard and failed to address the injury sustained from the environmental hazard for 1 resident (#80) of 18 residents reviewed. The facility's failure resulted in harm for Resident #80 who had entrapment of his left arm that resulted in soft tissue injuries. The findings include: Review of the facility policy MDS [Minimum Data Set] and Care Plan dated 5/2021, showed .A comprehensive, person-centered care plan includes objectives to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident . Medical record review revealed Resident #80 was admitted to the facility on [DATE], with diagnoses including Unspecified Dementia with Behavioral Disturbance, Psychotic Disorder with Hallucinations due to Parkinson's Disease, Tremor, Atherosclerotic Heart Disease,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-01-20 · 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 facility policy review, medical record review, and interview, the facility failed to update a comprehensive care plan to reflect changes in care needs due to a decrease in Activities of Daily Living (ADL) function for 1 resident (#17) of 18 residents reviewed for care plans. The findings include: Review of the facility's policy titled, MDS [Minimum Data Set] and Care Plan (Person Centered Care Plan) . dated 5/2021, revealed .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .care plans should be person centered, and unique for the residents' specific needs Quarterly care plans are updated during the MDS lookback period and up to seven days following the ARD [Assessment Reference Date] date . Resident #17 was admitted to the facility on [DATE] with diagnoses including Hypertension, Hip Replacement, and Alzheimer's Disease. Record review of the MDS quarterly assessment dated [DATE] revealed Resident #17 had severe cognitive…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-20 · 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 facility policy review, medical record review, review of facility documents, observation, and interviews, the facility failed to provide an environment free from potential accident hazards, failed to investigate an incident that led to injury, and failed to implement interventions to prevent further avoidable accidents for 1 resident (#80) of 7 residents reviewed for accidents. The findings include: Review of the facility policy Investigating Incidents dated 5/2021, showed .The staff with the input of the attending physician will implement interventions to reduce the specific risk factors . Medical record review revealed Resident #80 was admitted to the facility on [DATE], with diagnoses including Unspecified Dementia with Behavioral Disturbance, Psychotic Disorder with Hallucinations due to Parkinson's Disease, Tremor, Atherosclerotic Heart Disease, Diabetes, Recurrent Major Depressive Disorder, Generalized Anxiety Disorder, and History of Malignant Neoplasm of the Esophagus. Review of the Minimum Data…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · Fcited before2019-05-30 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, observation, and interview, the facility failed to ensure dishes, and food service equipment were clean and sanitary in 1 of 1 kitchen, affecting 102 of 103 residents. The findings include: Review of the facility policy, Dietary Services, revised 9/2018 revealed .Staff will safely and effectively .maintain sanitation . Review of the facility policy, Sanitization, revised 12/2018 revealed .All utensils, counters, shelves and equipment shall be kept clean .Kitchen .surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime . Review of the facility policy Ice Machine and Ice Storage revised 12/31/18 revealed .Ice machines containers will be used and maintained to assure a safe and sanitary supply of ice . Observation of the kitchen with the Certified Dietary Manager (CDM) on 5/28/19 at 10:55 AM, in the kitchen, revealed 5 serving bowls with dried food debris on the serving line and available for resident use, 1 meat slicer with the last used date unknown, uncovered with dried 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-05-30 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview the facility failed to maintain infection control practices during dining observation in 2 of 3 dining rooms and 1 of 4 halls observed, failed to follow contact isolation precautions for 1 resident (#63) of 1 resident observed for contact isolation, and failed to maintain infection control practices during 1 of 3 medication administration observations. The findings include: Review of the facility policy, Dining Room Audits, revised 1/2019 revealed .Frequent Sanitation of hands by hand sanitizer is recommended, if a staff member touches a resident or their belongings . Review of the facility policy, Contact Precautions, updated 12/2019 revealed .It is the intent of this facility to use contact precautions .for residents known or suspected to have serious illness easily transmitted by direct resident contact or by contact with items in the residents environment .Hand Hygiene should be completed prior to donning gloves. Gloves should…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-05-30 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 asses for use of a physical restraint and obtain a Physician's Order for a physical restraint prior to use for 1 resident (#45) of 4 residents reviewed for restraints of 22 sampled residents. The findings include: Review of the facility policy, Physical and Chemical Restraint, revised 9/2018 revealed .Prior to the use of a restraint other interventions may be used .the team will write orders with the doctors approval for devices or restraints as needed . Medical record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including Encephalopathy, Localized Edema, History of Falls, Dementia with Behavioral Disturbance, Major Depressive Disorder, Psychotic Disorder with Delusions, Anxiety Disorder, and Alzheimer's Disease. Medical record review of the Physician Recapitulation Orders dated 5/28/19 revealed an order had not been obtained for a table top restraint to be used with…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-05-30 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment timely for 1 Resident (#83) of 22 sampled residents. The findings include: Medical record review revealed Resident #83 admitted to the facility on [DATE] with diagnoses including, Type II Diabetes, Diabetic Neuropathy, Osteoarthritis, Nutritional Deficiency Episodes, Dementia with Behavioral Disturbance, and Psychotic Disorder. Interview with the MDS Coordinator on 5/30/19 at 1:30 PM, in the conference room, confirmed the MDS Coordinator signed and completed the quarterly MDS assessment on 5/7/19. Continued interview with the MDS Coordinator confirmed the quarterly MDS assessment was completed on 5/7/19 two days prior to the assessment reference date (ARD) date of 5/9/19. Interview with the Assistant Director of Nursing on 5/30/19 at 2:00 PM, in the Director of Nursing office, confirmed .MDS Coordinator should not have signed off on an assessment with an ARD date of 5/9/19 on 5/7/19 .

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-05-30 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to accurately complete a quarterly Minimum Data Set (MDS) assessment for the use of a physical restraint for 1 resident (#45) of 22 residents reviewed for comprehensive and quarterly assessments of 22 sampled residents. The findings include: Medical record review revealed the Resident #45 was readmitted to the facility on [DATE] with diagnoses including History of Falls, Dementia with Behavioral Disturbance, Psychotic Disorder with Delusions, Anxiety Disorder, and Alzheimer's Disease. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored a 99 on the Brief Interview for Mental Status (BIMS) indicating the resident was unable to complete the BIMS due severe cognitive deficit. Continued review revealed the resident had not been assessed for the use of a restraint. Observations of Resident #45 on 5/28/19 at 12:05 PM, 2:45 PM, and on 5/29/19 at 8:36 AM, 10:30 AM, and 2:30 PM, in the resident's room, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-05-30 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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 develop and implement a Comprehensive Care Plan for the use of a physical restraint for 1 resident (#45) of 4 residents reviewed for restraint care plans of 22 sampled residents. The findings include: Medical record review revealed Resident #45 was readmitted to the facility on [DATE] with diagnoses including History of Falls, Dementia with Behavioral Disturbance, Psychotic Disorder with Delusions, Anxiety Disorder, and Alzheimer's Disease. Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident scored a 99 on the Brief Interview for Mental Status (BIMS) indicating the resident had a severe cognitive deficit. Continued review revealed Resident #45 required extensive assistance of 2 staff for bed mobility, transfers, dressing, toileting, and hygiene. Medical record review of the Comprehensive Care Plan dated 4/8/19 revealed no documentation for the table top restraint. Interview with the MDS…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-05-30 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to revise the care plan in a timely manner for a nothing by mouth (NPO) Physician's Order regarding enteral feeding (artificial nutrition through a tube inserted into the abdomen) for 1 resident (#87) of 1 resident reviewed for NPO status and enteral feedings of 22 sampled residents. The findings include: Medical record review revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dysphagia, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), and Gastroesophageal Reflux Disease (GERD). Medical record review of the Comprehensive Care Plan dated 5/8/19 revealed the resident was on enteral feeding and was NPO. Continued review revealed the resident was at risk for choking and aspiration due to Dysphagia with the intervention of NPO .TUBE FEEDINGS ONLY . Further review revealed the interventions of .Monitor tolerance to diet texture and ability to swallow…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-05-30 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to administer an enteral feeding (artificial nutrition provided by tube inserted into the abdomen) at the correct rate as ordered by the Physician for 1 resident (#87) of 1 resident reviewed for enteral feedings of 22 sampled residents. The findings include: Review of the facility policy Enteral Nutrition revised 9/2018 revealed .Enteral nutrition will be ordered by the Physician . Medical record review revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dysphagia, Chronic Obstructive Pulmonary Disease (COPD), and Congestive Heart Failure (CHF). Medical record review of the Comprehensive Care Plan dated 5/8/19 revealed the resident required total assistance of 2 staff for all activities of daily living (ADL). Continued review revealed the resident was on enteral feeding and had a nothing by mouth (NPO) Physician's Order. Further review revealed a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-05-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to administer oxygen as ordered by the Physician for 1 resident (#87) of 4 resident's reviewed for oxygen therapy of 22 sampled residents. The findings include: Review of the facility's Oxygen policy revised 12/2018 revealed .There must be a physicians order for oxygen use . Medical record review revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dysphagia, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), and Generalized Anxiety Disorder. Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident scored an 11 on the Brief Interview for Mental Status (BIMS) indicating the resident had moderate cognitive impairment. Continued review revealed the resident received oxygen therapy. Medical record review of the Physician's Recapitulation Orders dated 5/1/19 - 5/31/19 revealed oxygen (O2) at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-05-30 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to follow Pharmacy recommendations for 1 resident (#2) of 5 residents reviewed for unnecessary medications of a total of 22 sampled residents. The findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Gastro- Esophageal Reflux Disease, and Chronic Obstructive Pulmonary Disease. Medical record review of a pharmacy Drug Regimen Review dated 4/29/19 revealed .Resident takes Prilosec (medication for heartburn) 20 mg (milligrams) since December 2018 and Claritin (medication for allergies) 10 mg since December 2018 .Recommend to assess need of continued scheduled use . Continued medical record review revealed the Physician signed and declined the pharmacy recommendation and failed to add rationale. Interview with the Director of Nursing (DON) and review of the pharmacy Drug Regimen Review dated 4/29/19, on 5/30/19 at 1:25 PM, in the DON office, confirmed the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$10,024 in federal fines across 2 penalties.

  • $5,012 — penalty dated 2024-05-17
  • $5,012 — penalty dated 2024-05-17

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 GREEN TREE HEALTH MANAGEMENT — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.9-0.9 vs chain
Health inspection 2 of 52.6-0.6 vs chain
Staffing 2 of 52.1-0.1 vs chain
Quality measures 3 of 54.0-1.0 vs chain
The other 7 homes this chain runs (chain average 2.9★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
ERWIN HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 09/01/2025
HORIZON HEALTHCARE GROUP LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF10%since 09/01/2025
STARLIGHT HEALTHCARE LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF45%since 09/01/2025
10-26 NATIONWIDE TROrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 09/01/2025
BCJ ENTERPRISES, LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 09/01/2025
CAPITAL HOLDINGS TRUSTOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 09/01/2025
JEREMIAS, BARUCHIndividualINDIRECT OWNERSHIP INTERESTsince 09/01/2025
JEREMIAS, SAMUELIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 09/01/2025
STERN, JACOBIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2025
CCH HEALTHCARE NC, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2025
ERWIN PROPCO LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2025
BENNETT, JASONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2025
COLINGER, JASONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2025
1026 ENTERPRISES II, LLCOrganizationADP OF THE SNFsince 09/01/2025

CMS files one row per role, so the 26 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

9 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.

$9.7M
Net patient revenuemost recent cost report
+6.3%
Operating marginrevenue minus expenses
$146K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 73%Medicare 13%Other / private 14%

About 73% 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 $146K 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

$260per resident / day
operating cost
$7,916per month
≈ monthly operating cost
$278per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TN

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Tennessee Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 445291. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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