Mulberry Health & 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.

33.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 43.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 23 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% 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 157 beds and averages 85.9 residents a day — about 55% occupied, or roughly 71 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 3.81 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.30 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.42 hrs/resident/day on weekends vs 3.97 on weekdays — 14% thinner on weekends. RN hours go from 0.34 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 68% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

This trend is not current. The most recent of these two inspections was over 3 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

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

35 citations, most serious first. The 15 most serious are shown; the remaining 20 are one tap away and print in full.

• Immediate jeopardy · Kcited before2021-07-19 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  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, video camera footage review, medical record review, observation, and interview, the facility failed to ensure adequate supervision of residents and ensure interventions were implemented for residents with physically aggressive and wandering/exit-seeking behaviors for 5 of 14 sampled residents (Resident #34, #80, #81, #91 and #96) reviewed for abuse. The facility's failure resulted in Immediate Jeopardy when Resident #80 willfully pushed Resident #81. Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. The facility's failure resulted in Immediate Jeopardy when Resident #34, #80, #81, #91 and #96 did not have supervision and interventions implemented for their behaviors. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2021-07-19 · tag F0726 — failed to have competent, trained nursing staff — pattern
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  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, agency contract review, employee personnel file review, observation, and interview, the facility failed to ensure licensed nurses and certified nursing assistants (CNA) had the knowledge and skills necessary to assess residents, prevent abuse, and provide appropriate care to meet the residents needs for 5 of 16 sampled residents (Resident #34, #80, #81, #91, and #96) with physically aggressive and wandering/exit-seeking behaviors. The facility's failure resulted in Immediate Jeopardy when Resident #80 willfully pushed Resident #81. Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. The facility's failure resulted in Immediate Jeopardy when Resident #34, #80, #81, #91, and #96 did not have supervision and interventions implemented for their aggressive behaviors. The failure of the licensed nurses and CNAs to identify behaviors and respond to those behaviors and the potential/likelihood of continued behaviors…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2021-07-19 · tag F0744 — failed to care for residents with dementia — pattern
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to meet each resident's Dementia care and behavior needs for 6 of 16 residents (Resident #34, #80, #81, #91, #96, and #303) reviewed for Dementia care and behaviors. The facility's failure to provide care and services for Dementia and behaviors resulted in Immediate Jeopardy when a physical altercation occurred between Resident #80 and #81, Resident #80 willfully pushed Resident #81, Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. A physical altercation occurred between Resident #96 and Resident #74, inappropriate sexual behavior occurred between Resident #303 and Resident #36, Resident #34 ran her wheelchair into Resident #16, Resident #85, ran over Resident #94's foot, and the state surveyors, and Resident #91, a cognitively impaired vulnerable resident with a history of behaviors and had verbalized 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
• Immediate jeopardy · K2021-07-19 · 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 policy review, job description review, and interview, facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well-being of the residents with behaviors and dementia. The Administration failed to provide oversight to monitor and provide a safe resident environment related to residents with behaviors and dementia. The Administration failed to provide oversight and training of staff to prevent abuse and provide appropriate care to meet residents needs with behaviors and dementia. These failures resulted in Immediate Jeopardy for Resident #34, #80, #81, #91, #96, and #303. The facility's failure resulted in Immediate Jeopardy when Resident #80 willfully pushed Resident #81. Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. The facility's failure resulted in Immediate Jeopardy when Resident #34, #80, #81,…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2021-07-19 · tag F0867 — failed to act on quality-improvement findings — pattern
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, Administrator job description review, Director of Nursing (DON) job description review, Registered Nurse (RN) job description review, Licensed Practical Nurse (LPN) job description review, medical record review, video camera footage review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to resident to resident abuse, failed to perform follow up on monitoring of residents with behaviors, failed to evaluate and re-evaluate interventions implemented for residents with behaviors, failed to ensure nursing staff were competent to provide care to residents with behaviors and Dementia, and failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to abuse, residents with Dementia and behaviors, and competent nursing staff. The QAPI committee failed to ensure the facility was administered in a manner that enabled it to use its…

  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 · Dcited before2023-10-27 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on policy review, document review, record review, and interview, the facility failed to protect the resident's right to be free from verbal abuse for 1 (Resident #4) of 7 residents reviewed for abuse. Dietary Staff (DS) DS #3 used profanity directed toward Resident #4 and called the resident a derogatory name. Findings included: 1. Review of the facility policy titled Resident Rights, revised in February 2021, indicated Employees shall treat all residents with kindness, respect and dignity . The policy further indicated that residents had the right to .b. be free from abuse, neglect, misappropriation of property, and exploitation . 2. Record review of the Resident Face Sheet revealed Resident #4 was admitted to the facility 01/13/2023, with diagnoses that included cognitive communication deficit, bipolar disorder, and pain disorder with related psychological factors. A review of Resident #4's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/20/2023, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated…

  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 before2023-10-27 · 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

  Based on policy review, document review, record review, and interview, the facility failed to ensure allegations of abuse and injuries of unknown origin were reported to the State Agency within two hours of learning of the allegations for 1 (Resident #1) of 7 residents reviewed for abuse. Findings included: 1. A review of an undated facility policy titled Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedures revealed, When the facility has identified abuse, the facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The Facility will increase enforcement action, including, but not limited to: A. Taking steps to prevent further potential abuse. B. Reporting alleged violations and investigation within required timeframes pursuant to Federal and State statutes and regulations. Section, XIII. Response revealed A. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility shall: a. Ensure that all alleged violations involving abuse, neglect,…

  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 · D2023-10-27 · 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

  Based on policy review, document review, record review, and interview, the facility failed to ensure a thorough investigation of an injury of unknown origin was completed for 1 (Resident #1) of 7 residents reviewed for abuse. Findings included: 1. A review of an undated facility policy titled Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedures, revealed, IV. When the facility has identified abuse, the facility will take all appropriate steps to remediate the noncompliance and protect residents additional abuse immediately. The facility will increase enforcement action including, but not limited to: C. Conducting a thorough investigation of the alleged violation. Further review revealed, V. The facility will develop written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation with the Quality Assurance and Performance Improvement (QAPI) program to allow the QAA (Quality Assessment and Assurance) committee to determine: a. If a thorough…

  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 before2023-10-27 · 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

  Based on record review, facility document review, and interviews, the facility failed to ensure proper transfer methods were used for 1 (Resident #1) of 3 residents reviewed for falls. Findings included: Review of Resident #1's Resident Face Sheet revealed the facility admitted the resident on 11/02/2022, with diagnoses that included unspecified intellectual disabilities and anxiety disorder. Review of Resident #1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/26/2023, revealed the Staff Assessment for Mental Status (SAMS) indicated the resident had a short and long term memory problem and their cognitive skills for daily decision making were severely impaired. The MDS indicated Resident #1 required extensive assistance from staff for bed mobility and transfers and was totally dependent on staff for locomotion on and off the unit, dressing, eating, toilet use, personal hygiene, and bathing. Review of a facility Occurrence Report dated 07/09/2023, revealed Registered Nurse (RN) #2 indicated Certified Nursing Assistant (CNA) #9 reported to her 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2023-06-15 · tag F0609 — failed to report abuse allegations — pattern
  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 review of facility policy, medical record review, facility investigations and interview, the facility failed to report the investigative outcome within 5 working days of the alleged violation for 3 of 3 allegations reviewed involving 5 residents (Resident #82, Resident #64, Resident #62, Resident #44, and #241) sampled for abuse. The findings include: 1. Review of the facility policy Abuse, Neglect and Exploitation undated showed .The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of the alleged violation . 2. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Altered Mental Status, Dementia with Behavioral Disturbances, and Psychosis. A quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment and exhibits…

  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 · D2023-06-15 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to inform of/or provide written information regarding a resident's right to formulate an advanced directive for 12 of 24 sample residents (Resident #8, #12, #18, #19, #20, #37, #41, #44, #50, #61, #73, and #82) residents reviewed. The findings include: 1. Review of the facility's policy titled, Advance Directives, with a revised date of 9/2022, revealed .The resident has the right to formulate an advance directive .upon admission of a resident, the social services director or designee inquires of the resident, his/her family .about the existence of any written advance directive .The resident or representative is provided with written information concerning the right to refuse or accept .and to formulate an advance directive . 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction and Epilepsy. Review of the quarterly Minimum Data Set (MDS) assessment dated…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-06-15 · tag F0640 — isolated
  Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete the admission assessment, using the Centers for Medicare & Medicaid Services-specific RAI (Resident Assessment Instrument) process within the regulatory time frames for 1 of 20 sampled residents (Resident #66) reviewed for completion of the MDS. The findings include: 1. Review of the MDS 3.0 RAI Manual v (version) 1.17.1 October 2019, page 2-37 revealed .using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames. 2. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE], with diagnoses of Dementia, Psychotic Disturbance, Anxiety, Bipolar Disorder, and Chronic Pain Syndrome. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], Resident #66 had moderately impaired cognition. Review of Resident #66's admission MDS with an Assessment Reference Date (ARD)…

  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 before2023-06-15 · 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 and interview, the facility failed to accurately assess residents for hospice for 2 of 2 (Resident #36 and #88) sampled residents reviewed. The findings include: 1. Review of the facility's policy titled, Resident Assessment, dated 2001, revealed .A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements .The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments .All person who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information . 2. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE], with diagnoses of Lung Cancer, Depression, Pain, Hypertension, and Dementia. Review of the Physician's Order dated 3/27/2023, revealed [Name Hospice] . Review of the admission MDS dated [DATE], revealed Resident #36 had a Brief Interview…

  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 before2023-06-15 · 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 conduct Care Plan meetings for 3 of 8 sampled residents (Resident #9, #44, and #50) and failed to revise the Care Plan for 1 of 19 sampled residents (Resident #41) reviewed for care planning. The findings include: 1. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 2001, revealed .A comprehensive, person-centered care plan that includes measurable objectives and timetabled to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care . 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-06-15 · 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

  Based on review of the facility policy, medical record review and interview the facility failed to monitor blood glucose levels as prescribed for 1 of 3 residents (Resident #13) reviewed related to blood glucose monitoring. The findings include: 1. Review of the facility policy Diabetes-Clinical Protocol revealed, .the Physician will order appropriate lab tests ( .finger sticks) [Accucheck] and adjust treatments based on these results . 2. Review of the signed physician's orders for Resident #13 dated 12/2022, 2/2023, 3/2023, and 4/2023 revealed .blood glucose monitoring .Schedule 11:30 AM; 4:30 PM; 6:00 AM; 9:00 PM . Review of the January 2023, Medication Administration Record (MAR) revealed there was no documentation the blood glucose level was obtained on the following days/times: On 1/2/2023 and 1/17/2023 at 11:30 AM before lunch l) no documentation of blood glucose level. On 1/16/2023 at 11:30 AM and 4:30 PM (before meal) and 9:00 PM (at bedtime check) blood glucose level. Review of the February 2023, MAR revealed there was no documentation the blood glucose level was obtained…

  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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

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

About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 10% 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