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Gallaway Health And Rehab

435 Old Brownsville Rd, Gallaway, TN 38036 · For profit - Limited Liability company · 104 certified beds · (901) 867-8575 Medicare & Medicaid certified

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Flagged for abuse1 immediate-jeopardy citation$78,741 in federal fines
Insights

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

Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $78,741 in federal fines (most recent 2025-08-27)
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (66%) runs well above the national median (45%)
  • its last standard health inspection was over 4 years ago — the star rating may not reflect current conditions

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Urgent care / clinic
5150 Airline Rd Ste 300 · (901) 752-6963 · Call to confirm hours
Pharmacy
5847 Airline Rd · (901) 586-1010 · Call to confirm hours
Grocery
11635 Highway 70 · (901) 290-9260 · Call to confirm hours
Park
12148 Forrest St · Typically dawn to dusk
Place of worship
588 Old Brownsville Rd · (901) 867-8449

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 1 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased27.2%14.0%15.4%worse
Long-stay residents who lose too much weight6.5%6.1%5.4%worse
Long-stay residents with a catheter left in their bladder1.4%0.7%0.9%worse
Long-stay residents with a urinary tract infection4.4%1.8%2.0%worse
Long-stay residents with depressive symptoms0.4%13.8%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.3%0.1%0.1%worse
Long-stay residents with falls causing major injury2.0%3.4%3.3%better
Long-stay residents whose ability to walk worsened31.4%17.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication14.3%31.7%18.9%better
Long-stay residents given the seasonal flu vaccine96.7%94.5%95.3%typical
Long-stay residents with pressure ulcers7.9%5.0%4.7%worse
Long-stay residents with worsening bladder/bowel control25.6%20.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table53.5%16.8%17.1%check this — see note marked dagger below the table
Short-stay residents who newly got an antipsychotic medication6.0%1.7%1.4%worse
Short-stay residents given the seasonal flu vaccine84.4%79.8%79.4%typical
Short-stay residents rehospitalized after admission23.1%22.6%22.6%typical
Short-stay residents with an outpatient ER visit18.2%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.091.671.67worse
Long-stay outpatient ER visits per 1,000 resident days2.301.561.80worse

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

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.

39.0% 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 45 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

39.0%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
31.7%U.S. median 56.6%
Met the expected recovery
0.23U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 31.7% 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 41 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 5% 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 SNF39.0%CMS range 27.8–52.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 7.5–13.610.7%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 discharge31.7%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 discharge39.0%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 discharge34.1%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 identified87.9%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 setting96.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.5%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 worsened3.0%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 hospitalization7.4%CMS range 4.0–11.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.931.02Oct 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

0.47
RN hours/ resident / day
0.80
LPN hours/ resident / day
1.67
Aide hours/ resident / day
2.94
Total nurse hours/ resident / day
0.41
RN hoursweekends
65.9%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 104 beds and averages 90.5 residents a day — about 87% occupied, or roughly 14 beds typically open. It runs fairly full. 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 2.94 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.67 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 2.51 hrs/resident/day on weekends vs 3.12 on weekdays — 19% thinner on weekends. RN hours go from 0.50 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 66% 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

6
deficiencies at the latest standard inspection (2022-06-09)
7
at the previous standard inspection (2019-06-27)

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 4 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.

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.

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · J2025-08-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, email correspondence review, observation, and interview, the facility failed to protect the residents' right to be free from neglect for 3 of 14 (Resident #6, Resident #1, and Resident #12) sampled residents reviewed for abuse and neglect. Resident #6, a vulnerable, cognitively impaired, totally dependent resident who required enteral feeding (method of delivering nutrition directly into the gastrointestinal tract) for nutrition was reviewed for neglect. On 3/20/2025, the nurse documented Resident #6 had a tear on the side of the feeding port of the percutaneous endoscopic gastrostomy (PEG) tube which caused leakage of the feeding onto the bed. Resident #6 did not receive a new PEG tube until 4/7/2025, 19 days after the tear was found, which allowed for leakage of the enteral nutrition for 19 days. Resident #6's weight was 137 pounds (lbs.) on 3/14/2025 and decreased to 117 lbs. on 4/3/2025. Resident #6 sustained a severe weight loss of 14.59 percent (%) in…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-18 · tag F0835 — failed to run the facility competently — isolated
    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

    Based on personnel file review, facility document review and interview, Administration failed to ensure that nursing services were provided by qualified personnel when the facility hired an imposter nurse (Imposter Nurse A) to function as a Licensed Practical Nurse (LPN) using another LPN's (LPN C) Tennessee license. The findings include: Review of Imposter Nurse A's personnel file revealed a letter from a Tennessee Criminal History Record Request for Imposter Nurse A's first and last name revealed, .NO TENNESSEE CRIMINAL HISTORY RECORD HAS BEEN FOUND FOR THE PERSON LISTED BELOW. There was no national background check found in the personnel file. Review of the I-9 form (Employment Eligibility Verification) used to verify the identity and legal authorization of individuals hired for employment in the United States dated 04/11/2023, revealed Imposter Nurse A's legal first and last name, along with a birth certificate and a valid Driver's license from another state. The last name used on the I-9 form was the same as the Driver's license. Review of a license verification form 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-27 · 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, and interview, the facility failed to develop and implement a person-centered care plan for 1 of 3 (Resident #3) sampled residents reviewed. The findings include: 1.Review of the undated facility policy titled, KARDEX revealed, .the KARDEX is a vital section that outlines each resident's individualized daily care plan. It provides detailed instructions on various aspects of care, including the resident's daily activities.includes information on the resident's mobility.specific safety needs.and transfer methods.It notes whether the resident can ambulate independently. Review of the facility policy titled, F 656, F 657, F 658 Comprehensive Care Plans, with an effective date of 3/2025 revealed, .An individualized comprehensive person centered care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental cultural and psychological needs is developed for each resident. Assessments of residents are ongoing and care…

    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 · Fcited before2022-06-09 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, review of Employee Screening logs and employee time sheets, observation, and interview, the facility failed to ensure practices to maintain the spread of infection were maintained when 14 of 47 staff (Certified Nursing Assistant (CNA) #1, #2, #3, and #4, Licensed Practical Nurse (LPN) #1, #2, and #3, Housekeeper #1, #2, and #3 and Dietary Aide #1, #2, #3 and #4) failed to complete screening for the prevention and detection of COVID-19 prior to working on 2 of 2 days (5/25/2022 and 5/28/2022) reviewed and when 1 of 4 nurses (LPN #7) failed to properly clean and store enteral feeding syringes after use for 2 of 2 sampled residents (Resident #65 and #75) observed. This had the potential to affect the 90 residents residing in the facility. The findings include: Review of the CDC document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/2022, revealed .Recommended routine infection prevention…

    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 · Ecited before2022-06-09 · tag F0580 — failed to tell family and doctor about changes — pattern
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to notify the Physician and patient representative for an allegation of abuse for 1 of 7 sampled residents (Resident #11) reviewed for abuse and the facility failed to notify patient representatives of changes in pressure ulcer status for 2 of 3 sampled residents (Resident #36 and Resident #388) reviewed for pressure ulcers/injuries. The findings include: Review of the facility's policy titled, Reporting of Abuse Allegations, revised 11/2017, revealed .All suspected violations and all substantiated incidents of abuse .Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse .) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons (verbally or written) of such incident .The State Licensing/recertification agency .The resident's Attending Physician .The facility Medical…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-09 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, facility investigation review, medical record review, and interview, the facility failed to timely and thoroughly investigate an incident of resident-to-resident abuse for 2 of 7 sampled residents (Resident #11 and #32) reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse Investigations, revised 11/2017, revealed .Reports of resident abuse .shall be promptly and thoroughly investigated by facility management .The individual conducting the investigation will, as a minimum .Review the completed documented forms .Interview any witnesses to the incident .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview the resident's roommate .Witness reports will be obtained in writing . Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Schizophrenia, Dementia, and Psychotic Disorder Review of the quarterly Minimum Data Set (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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-06-09 · 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 policy review, medical record review, and interview, the facility failed to develop a comprehensive Care Plan for Dementia for 2 of 4 sampled residents (Resident #10 and #62) reviewed. The findings include: The facility's policy titled, Care Plans - Comprehensive, revised 11/2017, revealed .And individualized comprehensive person centered care plan that includes measurable objectives and time frames to meet the resident medical, nursing, mental and psychological needs is developed for each resident . Review of the medical record, revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of Dementia, Atrial Fibrillation, Dysphagia, and Major Depressive Disorder. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #10 had Non-Alzheimer's Dementia. Review of the Care Plan dated 2/28/2022, revealed there was no comprehensive Care Plan for Dementia. Review of the medical record, revealed Resident #62 was admitted to the facility on [DATE] with diagnoses of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-09 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to ensure the completion of a discharge summary that included a recapitulation of the resident's stay, the disposition status of the resident at the time of discharge, and a post discharge plan of care for 1 of 1 sampled residents (Resident #388) reviewed for discharge. The findings include: Review of the facility's policy titled, Discharge Summary and Plan, revealed .When a resident's discharge is anticipated, a discharge summary and post-discharged plan will be developed .The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of discharge .The recapitulation will include .diagnoses, Course of illness, treatment or therapy, Pertinent lab, radiology and consultation results, reconciliation of all pre-discharge medications with the resident's post discharge medications .a final summary paragraph . Review of the medical record, 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 · D2022-06-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 4 nurses (Licensed Practical Nurse (LPN) #7) followed policies and procedures for the administration of medication through a Percutaneous Endoscopic Gastrostomy (PEG) tube for 1 of 2 sampled residents (Resident #65) observed and the facility failed to ensure Physician Orders for lab were followed for 1 of 5 sampled residents (Resident #9) reviewed for lab services. The findings include: Review of the facility's policy titled, Administering Medication Through an Enteral Tube, revised 2/2018, revealed .The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube .Dilute powdered, crushed, or split (capsule) medications at the bedside . Review of the medical record, revealed Resident #65 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Schizophrenia, Gastrostomy, and Depression. Review of the Physician's Orders dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2019-06-27 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Service Agreement review, policy review, observation, and interview, the facility failed to provide effective housekeeping services and maintenance services to maintain a sanitary, orderly, and comfortable environment as evidenced by missing ceiling tiles, missing grout in tiles, brown debris and brownish and black build-up on the floors and in corners of rooms, unpainted, exposed plaster, brownish build-up on window ledges, blinds, and air conditioners, air conditioners with missing pieces, discolored grout in bathrooms, worn linoleum floors exposing subflooring, gray areas on ceiling tiles, unclean, broken and rust colered resident equipment, unclean exhaust fans, brown substance and stains in sinks and on commodes, holes in walls, loose and broken tiles and base boards, bulging and crumbling dry wall, odors, gouged and scratched walls, peeling paint; corroded faucets, missing covers on lights, an improperly hanging door, and mismatched floor tiles in 44 of 57 (101, 102, 103, 104, 105, 106, 107, 108,…

    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 · F2019-06-27 · 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 policy review, observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by a dirty bowl stacked in clean bowls, chipped plates, a dirty ice machine, a mound of ice in the walk-in freezer, a dirty freezer floor, staff allowing dirty dishes to come in contact with clean dishes, wet nesting of dishes [stacking of wet items, such as pans and dishes], staff touched clean dishes with dirty gloves, and staff stored personal food in a resident nutrition refrigerator. The facility had a census of 93 with 91 of those residents receiving a meal tray from the kitchen. The findings include: 1. The facility's Sanitization policy revised 2017, documented, .The food service area shall be maintained in a clean sanitary manner .Utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning .Plastic-ware, china and glassware that cannot be sanitized or are hazardous…

    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
Show the remaining 10 citations
  • Potential for harm · E2019-06-27 · tag F0865 — failed to run a quality-improvement (QAPI) program — pattern
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program, failed to recognize an ongoing environmental concern, and failed to provide effective housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment. The QAPI committee failed to identify the root cause of the concerns, develop appropriate plans of action, and ensure systems and processes were in place to address the concern. The failure of the QAPI Committee to ensure the facility implemented and provide effective housekeeping services and maintenance services to maintain a sanitary, orderly and comfortable environment for 44 of 57 (101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 117, 118, 119, 121, 122, 123, 124, 125, 126, 128, 130, 219, 220, 221, 225, 226, 227, 228, 230, 231, 232, 233, 234, 235, 241, 244, 245, 246, and 247) resident rooms observed resulted in Substandard Quality of Care. The Administrator and Director of Nursing (DON) were notified of the Substandard Quality of…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-06-27 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 3 of 3 (Wound Care Nurse, Certified Nursing Assistant (CNA) #5, Licensed Practical Nurse (LPN) #1) staff members failed to perform proper hand hygiene during 3 of 3 (Resident #7, #21, and #41) observations of provision of care and dirty linens were left on the bathroom floor in 1 of 3 (100 Hall Central Bath) shower rooms and 1 of 42 (room [ROOM NUMBER]) resident room bathrooms. The findings include: 1. The facility's Handwashing/Hand Hygiene policy with a revision date of April 2010 documented, .This facility considers hand hygiene the primary means to prevent the spread of infections .Employees must wash their hands .Before and after direct contact with residents .After removing gloves .The use of gloves does not replace handwashing/hand hygiene . 2. Medical record review revealed Resident #7 was admitted to the facility on [DATE]…

    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 · E2019-06-27 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure 1 of 2 (100 Hall Dayroom) dayrooms, 2 of 2 (100 Hall and 200 Hall) halls, and 3 of 3 (100 hall Central Shower, Secure Unit Women's Shower, and Secure Unit Men's Shower) shower rooms were clean and sanitary. The findings include: 1. Observations in the 100 Hall Dayroom on 6/24/19 at 9:12 AM, 11:39 AM, 2:49 PM, 6/25/19 at 8:04 AM, and 3:38 PM, and on 6/26/19 at 7:46 AM revealed black streaks on the floor, brown debris, stains and scattered debris on the floor. The windows were cloudy and smeared with a grayish white substance between the dayroom and the nurses' station. Interview with the Housekeeping District Manager on 6/27/19 at 10:16 AM in the Conference Room, revealed the Housekeeping District Manager was asked if the common areas and dayrooms should be kept clean and sanitary. The Housekeeping District Manager stated, Yes. 2. Observations in the 100 Hall on 6/24/19 at 7:55 AM, 9:10 AM, 11:45 AM, 2:23 PM, 6/25/19 at 8:01 AM, 3:25 PM, and on 6/26/19 at 7:46 AM revealed brown debris, brownish-black stained areas, 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure the safety of a resident during transfer for 1 of 6 (Resident #35) sampled residents reviewed for accidents. The findings include: 1. The facility's Lifting Machine, Using a Portable policy with a revision date of October 2010 documented, .Preparation .Review the resident's care plan to assess for any special needs of the resident .General Guidelines .The portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, two (2) nursing assistants will be required to perform the procedure .Documentation .The following information should be recorded in the resident's medical record .Any problems .related to the procedure .Report other information in accordance with facility policy and professional standards of practice . The facility's Fall and Fall Risk, Managing policy with a revision date of November 2017 documented, .Fall Definition .Unintentionally coming…

    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 · D2019-06-27 · 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 policy review, observation, and interview the facility failed to ensure that waste was disposed of properly for 1 of 1 dumpster observed. The findings include: The facility's Food-Related Garbage and Rubbish Disposal policy dated November 2017, documented .Outside dumpsters .will be kept closed and free of surrounding litter . Observations of the dumpster on 6/26/19 at 7:56 AM revealed trash on the ground completely surrounding the dumpster. The trash included old used disposable gloves. Observations of the dumpster on 6/26/19 at 6:30 PM revealed the doors of the dumpster partially open with trash bags sticking out and trash, including more than 12 used disposable gloves, scattered on the ground surrounding the dumpster. Observations of the dumpster on 6/27/19 at 7:36 AM revealed the doors of the dumpster partially open with trash bags sticking out and trash scattered around the dumpster. Interview and observation with the Dietary Manager (DM) on 6/27/19 at 7:58 AM in the dumpster area, revealed trash bags sticking out of the dumpster and trash on the ground around 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2018-09-06 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to notify the physician of blood glucose (blood sugar) results for 1 of 5 (Resident #46) sampled residents. The findings include: 1. The Obtaining a Fingerstick Glucose Level policy with a revision date of October 2010 documented, .The person performing this procedure should .Report results promptly to .the Attending Physician . 2. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and Type 2 Diabetes Mellitus. The Medication Administration Record (MAR) for the month July, August, and September 2018 documented, .Insulin Lispro Solution .Inject as per sliding scale .>[greater than] 349, give 6 units and call physician . The MAR documented the following blood glucose results: a. 390 on 7/26/18 at 4:00 PM b. 496 on 7/28/18 at 4:00 PM c. 356 on 7/30/18 at 4:00 PM d. 350 on 8/28/18 at 7:30 AM e. 350 on 8/29/18 at 11:00 AM f. 352 on 8/30/18 at 7:30 AM and 350 at 4:00…

    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 · D2018-09-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter when nursing staff failed to keep the drainage bag off the floor for 1 of 2 (Resident #93) sampled residents reviewed for indwelling urinary catheters. The findings include: The facility's Indwelling Urinary Catheters . policy with a revision date of 11/17, documented, .Be sure the catheter tubing and drainage bag are kept off the floor . Medical record review revealed Resident #93 was admitted to the facility on [DATE] with diagnoses of Neuromuscular Dysfunction of Bladder, Hypertension, and Hyperlipidemia. The physician's orders dated 8/7/18 documented, .Indwelling (foley) catheter .16ff [french]/10cc [cubic centimeters] . Observations in Resident #93's room on 9/4/18 at 9:05 AM, 2:23 PM, and 3:13 PM, revealed Resident #93 seated in a wheelchair with the indwelling catheter drainage bag hanging underneath the chair and touching the floor.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-09-06 · 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 policy review, medical record review, observation, and interview, the facility failed to follow physician orders related to an enteral feeding for 1 of 1 (Resident #52) sampled resident reviewed for enteral feeding. The findings include: The facility's Enteral Nutrition . policy with a revision date of 11/16, documented, .Enteral feeding orders will be written to ensure consistent volume infusion .Fluids to be provided (beyond free fluid in product) will be calculated by the Dietician and referred to the Physician for an order . Medical record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses of Adult Failure to Thrive, Gastrostomy Status, Dementia, and Diabetes. The significant change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment, required staff assistance for all activities of daily living, received tube feedings, and received 51 percent or more calories and 501 cubic…

    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 · D2018-09-06 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 4 (Licensed Practical Nurse (LPN) #2) nurses properly disposed of a topical medication patch during medication administration, and failed to ensure medications were not stored past their expiration dates in 1 of 6 (100 Medication Room) medication storage areas. The findings include: 1. The facility's Discarding and Destroying Medications . policy with a revision date of 6/12, documented, .Ointments, creams, and other like substances may be discarded into the trash receptacle in the medication room .Expired medications will be disposed of per state or contracted pharmacy guidelines . 2. Medical record review revealed Resident #199 was admitted to the facility on [DATE] with diagnoses of Dementia, Pneumonia, Seizures, and Chronic Obstructive Pulmonary Disease. The physician's order dated 8/31/18 documented, .Rivastigmine Patch 24 Hour [medication patch used to treat dementia] 9.5 MG [milligrams]/24HR…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2018-09-06 · 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

    Based on observations and interview, the facility failed to ensure personal care items were stored in a sanitary manner in 2 of 42 (shared bathroom of Resident #12, 15, and 87, and shared bathroom of Resident # 51 and 60) bathrooms. The findings include: The facility was unable to provide a policy for storage of personal care items. Observations made in the shared bathroom of Residents #12, 15, and 87 on 9/4/18 at 9:12 AM, revealed an uncovered, unlabeled bath basin on top of the toilet, an unlabeled bottle of shampoo/body wash on the sink, an unlabeled tube of toothpaste and an unlabeled toothbrush on top of the soap dispenser. Observations made in the shared bathroom of Residents #12, 15, and 87 on 9/4/18 at 3:01 PM, revealed an unlabeled bath basin in an unlabeled plastic bag with the unlabeled shampoo/body wash inside on the top of the toilet, an unlabeled tube of tooth paste and an unlabeled toothbrush remained on top of the soap dispenser. Observations made in the shared bathroom of Residents #12, 15, and 87 on 9/5/18 at 9:08 AM, and on 9/6/18 at 7:57 AM, revealed 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.

    Infection Control 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

$78,741 in federal fines across 1 penalty.

  • $78,741 — penalty dated 2025-08-27

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.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

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.

$9.3M
Net patient revenuemost recent cost report
-3.4%
Operating marginrevenue minus expenses
$484K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 80%Medicare 7%Other / private 13%

About 80% 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 $484K 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

$311per resident / day
operating cost
$9,462per month
≈ monthly operating cost
$301per 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 445440. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2022-06-09, 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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