Renaissance Terrace
257 Patton Lane, Harriman, TN 37748 · For profit - Corporation · 130 certified beds · (865) 354-3941 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0569)
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- about 23% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 3 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 21.8% | 14.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.9% | 6.1% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.7% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 1.2% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 6.7% | 13.8% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.3% | 3.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 24.9% | 17.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 19.9% | 31.7% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.2% | 5.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 17.2% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.8% | 16.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.7% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 76.2% | 79.8% | 79.4% | typical |
§ 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.
Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 130 beds and averages 41.3 residents a day — about 32% occupied, or roughly 89 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 3.22 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.87 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.01 hrs/resident/day on weekends vs 3.31 on weekdays — 9% thinner on weekends. RN hours go from 0.97 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. 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.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · D2026-02-10 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the facility admission agreement review, medical record review, and interview the facility failed to timely disburse resident refunds due the responsible party for 1 resident (Resident #6) of 3 residents reviewed for resident funds. The findings include: Review of the admission agreement dated [DATE], revealed .Refunds due to you .If you are discharged or transferred, we will refund you any credit balance minus any outstanding private insurance balance within a reasonable time not to exceed thirty (30) days after we have applied such balances towards outstanding fees for services provided by us . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Unspecified Cerebral Infarction (Stroke), Chronic Congestive Heart Failure, and Metabolic Encephalopathy. Review of the medical and financial records for Resident #6 revealed the responsible party for Resident #6 was listed on the admission documents, admission face sheet, financial records, 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.
- Potential for harm · D2026-02-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 an Online Professional Journal review, medical record review, and interviews, the facility failed to follow established clinical guidelines related to urinary catheterization of using silicone coated latex urinary catheters in persons with known latex allergies for 1 resident (Resident #9) of 8 residents reviewed for urinary catheters.The findings include: Review of the Clinical Standards of Practice as Published in the Online Professional Journal titled Urology and Continence Care Today, dated 2/2026, with an article titled .Best Practice in the use of indwelling catheterization . revealed .Polytetrafluorethylene (PTFE, a type of silicone) coated catheters .These are latex catheters coated in PTFE, which is smoother than latex and can be useful in reducing encrustation and discomfort for the wearer .There is still risk of latex allergy and, therefore, PTFE coated catheters must be avoided in patients with a known allergy or sensitivity . Medical record review revealed Resident #9 was admitted to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-20 · tag F0584 — failed to keep a safe, clean, comfortable home — widespreadHonor 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 observation and interview, the facility failed to maintain resident rooms and hallways in good repair and in a homelike environment for 18 resident rooms (#23, #8, #21, #20, #27, #100, #30, #9, #101, #18, #5, #32, #31, #102, #103, #104, #13, #38, #10, #105, #106, and #14) of 34 rooms observed of 37 total rooms and 3 of 4 hallways observed which affected 22 residents. The findings include: During an environment tour of 4 Halls and 37 rooms on, 8/28/2023 starting at 10:00 AM and ending at 12:00 PM, the following concerns were observed: room [ROOM NUMBER]A (Resident #23) was observed to have scratched/gouged/scuffed walls and missing paint. room [ROOM NUMBER]B (Resident #8) was observed to have a dirty privacy curtain with circular brown stains. room [ROOM NUMBER]A (Resident #21) was observed to have scuffed walls and cracked sheet rock around the air conditioner (A/C) unit. room [ROOM NUMBER]A (Resident #20) was observed to have large scratches in the dry wall and missing paint on the wall over the bed.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-20 · tag F0641 — widespreadEnsure 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 review of The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, observation, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 19 residents (Resident #8, #10, #11, #12, #13, #14, #18, #19, #20, #21, #22, #23, #27, #30, #31, #32, #37, #38, and #39) for use of side rails, 2 residents (Resident #11 and #23) for dental needs, 2 residents (Resident #11 and #30) for respiratory care, and 1 resident (Resident #21) for significant weight loss of 19 residents reviewed for MDS assessments. The findings include: Review of the Resident Assessment Instrument (RAI) Manual dated 10/2019, showed .The RAI process has multiple regulatory requirements .the assessment accurately reflects the resident's status .a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals .the assessment process includes direct observation, as well as communication with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-20 · tag F0679 — failed to provide activities — widespreadProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation, and interview, the facility failed to provide a person-centered activities program which affected 4 of 4 residents (Resident #5, #19, #23, and #36) reviewed for activities which had the potential to affect all 40 residents in the facility. The findings include: Review of the facility policy titled, Life Connection Program, dated 3/2023, showed .Life connections programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident .the life connections program is ongoing and includes facility-organized group activities, independent individual activities, and assisted individual activities .activities are scheduled 7 days per week .scheduled activities are posted on the resident bulletin board .activity scheduled are also provided individually . Resident #5 was admitted to the facility on [DATE] with diagnoses to include Chronic Ischemic Heart Disease and Hypothyroidism. Review of a quarterly Minimum Data Set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-20 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 observation, and interview, the facility failed to ensure sufficient staff to provide person-centered activities for 4 of 4 residents (Resident #5, #19, #23, and #36) reviewed for activities and 3 of 4 residents (Resident #5, #19, and #36) reviewed for communal dining service which had the potential to affect all 40 residents present in facility. The findings include: Resident #5 was admitted to the facility on [DATE] with diagnoses to include Chronic Ischemic Heart Disease and Hypothyroidism. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. During an interview on 8/29/2023 at 3:20 PM, Resident #5 stated he did not know what or when activities were occurring, there were no consistent out of room activities, and the last BINGO group activity was over 2 weeks ago due to the lack of sufficient staff. Resident #5 also stated the dining room had been closed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observation, and interview the facility failed to ensure frozen food products were labeled and dated appropriately while stored in 1 of 2 freezers observed which had the potential to affect all 40 residents of the facility. The findings include: Review of the facility policy titled, Food Receiving and Storage, dated 7/24/2023, showed .Foods shall be received and stored in a manner that complies with safe food handling practices .All food stored in the refrigerator or freezer will be covered, labeled and dated (use by date) .Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee according to state-specific requirements . During the initial kitchen tour observation on 8/28/2023 at 10:45 AM, with the Dietary Manager (DM) #1 showed the vertical freezer had items without labels or opened/use by dates. A zip-locked pack (transferred from original packaging) of 4 pork-chops was noted without proper labeling of contents, date opened, or use by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-20 · tag F0867 — failed to act on quality-improvement findings — widespreadSet 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 facility policy review, review of Quality Assurance Performance Improvement (QAPI) documents, and interview, the facility's QAPI committee failed to monitor, implement appropriate plans to correct, and track the identified concerns related to a homelike environment with resident rooms being in disrepair and the use of side (bed) rails to ensure routine/scheduled maintenance assessments were completed which had the potential to affect all 40 residents of the facility. The findings include: Review of the facility policy titled, Quality Assessment and Performance Improvement, undated, showed .the facility will implement and maintain a Quality Assessment and Performance Improvement program .The program should address all systems of care and management practices while emphasizing safety .The primary purpose .is to identify and analyze actual or potential quality issues .and implement appropriate plans to improve performance .The minutes of the monthly QAPI meeting will be reviewed with the Medical Director…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-20 · tag F0909 — failed to maintain a comfortable temperature — widespreadRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
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, observations, and interviews the facility failed to ensure routine and regular scheduled side rail assessments were completed to identify the risk of entrapment for 19 residents (Resident #8, #10, #11, #12, #13, #14, #18, #19, #20, #21, #22, #23, #27, #30, #31, #32, #37, #38, and #39) of 19 residents reviewed for side rail assessments. The findings include: Review of the facility policy titled, Bed Rails, dated 5/10/2017, showed .A side rail assessment screen is completed on each resident upon admission, quarterly, and as needed .The assessment and documentation .includes .measuring the gaps between the rail(s) themselves and the gaps between the bed-rail and the mattress .Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks . Resident #8 was admitted to the facility on [DATE] with diagnoses to include Hemiplegia and Hemiparesis, Speech and Language Deficits,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-20 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 a comprehensive care plan for 1 resident (Resident #11) for dental concerns of 16 residents reviewed for dental concerns, and for 2 residents (Resident #13 and #14) for use of bed/side rails of 19 residents reviewed. The facility failed to implement the comprehensive care plan for 1 resident (Resident #38) related to identifying and documenting behaviors and side effects of psychotropic medications of 5 residents reviewed for unnecessary medications.The facility also failed to implement the comprehensive care plan related to falls for 1 resident (Resident #27) of 3 residents reviewed for falls. The findings include: Review of the facility policy titled, Care Plan-Comprehensive, undated, showed .It is the policy of this facility to develop comprehensive care plan for each resident that includes measurable objectives .to meet the resident's medical, nursing .needs .The comprehensive care plan had been designed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · E2023-09-20 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, and interview, the facility failed to follow a physician's order for 1 resident (Resident #10) to obtain a Prothrombin Time/International Normalized Ratio (PT/INR-blood test which shows how how long it takes for your blood to clot) of 2 residents reviewed for PT/INR, failed to obtain a Physician's Order for pressure ulcer wound care for 1 resident (Resident #10) of 1 resident reviewed for wounds, and failed to obtain a Physician's Order for side rails for 5 residents (Resident #8, #11, #13, #14, and #30) of 19 residents reviewed for side/bed rails. The findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses to include Cerebrovascular Disease, Type 2 Diabetes, Atrial Fibrillation, and Long-Term Use of Insulin. Review of a Physician's Order dated 8/22/2023, showed .Draw INR [PT/INR] on 08/29/2023 . Review of Resident #10's laboratory (lab) results showed a PT/INR result had not been obtained on 8/29/2023 as ordered. During an interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-20 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, review of manufacturer guidelines, medical record review, observation, and interview, the facility failed to complete side (bed) rail assessments, failed to accurately assess all bed frames, mattresses, and bed rails for the risk of entrapment for 18 residents (Residents #8, #10, #11, #12, #13, #14, #18, #19, #20, #21, #22, #27, #30, #31, #32, #37, #38, and #39) and failed to obtain consents for side rails for 5 residents (Residents #8, #13, #14, #20, and #21) of 19 residents reviewed for side rails. The findings include: Review of the facility policy titled, Bed Rails, dated 5/10/2017, showed .Before using a side rail for any reason, the staff shall inform the resident and or family/responsible party .A side rail assessment screen is completed on each resident upon admission, quarterly, and as needed .The assessment and documentation .includes .measuring the gaps between the rail(s) themselves and the gaps between the bed-rail and the mattress . Review of the Medline Operation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-20 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to maintain an accurate medical record as evidenced by failure to ensure the Advance Directive Acknowledgement Form had been completed for 5 residents (Resident #18, #20, #22, #32, and #38) and failed to complete an accurate side (bed) rail assessment for 2 residents (Resident #20 and #27) of 19 residents reviewed and failed to fully complete fall investigations for 2 residents (Resident #21 and #27) of 3 residents reviewed for falls. The findings include: Review of the facility policy titled, Bed Rails, dated 5/10/2017, showed .Before using a side rail for any reason, the staff shall inform the resident and or family/responsible party .A side rail assessment screen is completed on each resident upon admission, quarterly, and as needed .The assessment and documentation .includes .measuring the gaps between the rail(s) themselves and the gaps between the bed-rail and the mattress . Review of the facility policy titled,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-20 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation, and interview the facility failed to maintain infection control practices while delivering meal trays to residents on 1 hallway of 4 hallways observed. The findings include: Review of the facility policy titled, Handwashing/Hand Hygiene, last revised 6/2010, showed .This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections .Employees must wash their hands .under the following conditions .Before and after direct resident contact .After removing gloves .In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled .Before and after direct contact with residents .Before donning .gloves .After contact with objects .in the immediate vicinity of the resideny . During an observation of meal delivery on 8/28/2023 at 11:48 AM, on the A hallway, showed the following: Certified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-20 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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 facility policy review, observation, and interview, the facility failed to provide education to formulate an Advanced Directives for 1 resident (Resident #8) of 16 residents reviewed. The findings include: Review of the facility policy titled, Advanced Directives, dated 11/2022, showed .The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy .Advance Directive .a written instruction, such as a living will or durable power of attorney for healthcare, recognized by state law (whether statutory or as recognized by the courts of the state) .relating to the provisions of health care when the individual is incapacitated .The resident or representative is provided with written information concerning the right .to formulate an advance directive if he or she chooses to do so .If the resident is incapacitated and unable to receive information about his or her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-20 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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, facility documentation, local law enforcement investigation, observation, and interview the facility failed to protect the resident's right to be free from physical abuse by Certified Nursing Assistant (CNA) #2 for 1 resident (Resident #39) of 3 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, updated 10/2022, showed .Residents have the right to be free from abuse .This includes but not limited to freedom from .mental .or physical abuse .Protect residents from abuse .by anyone including .facility staff .other residents . Resident #39 was admitted to the facility on [DATE], with diagnoses to include Cerebral Infarction, Hemiplegia, Unspecified affecting Right Dominant Side, Dementia with Behavioral Disturbance, Major Depressive Disorder, and Anxiety Disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation, and interview, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 2 residents (Resident #11 and #30) of 11 residents reviewed for respiratory care. The findings include: Review of the facility policy titled, Oxygen Administration, dated 8/25/2014, showed .check the mask .to be sure they are in good working order and securely fastened .observe resident upon setup and periodically thereafter .used supplies into designated containers . Resident #11 was admitted to the facility on [DATE] with diagnoses to include Obstructive Sleep Apnea and Paraplegia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #11 was cognitively intact, and had an active diagnosis for Obstructive Sleep Apnea. Review of Resident #11's comprehensive care plan dated 4/27/2023, showed use of Continuous Positive Airway Pressure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-20 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to post daily staffing for 2 of 5 days reviewed. During an observation on 8/28/2023 at 10:36 AM, the daily staffing sheet had not been posted. During an interview on 8/28/2023 at 10:48 AM, the Director of Nursing (DON) confirmed the daily staffing sheet had not been posted. During an observation on 8/29/2023 at 2:10 PM, the daily staffing sheet was dated 8/28/2023. The daily staffing sheet had not been posted for 8/29/2023. During an interview on 8/29/2023 at 2:11 PM, the DON confirmed the daily staffing sheet had not been posted on 8/28/2023 and 8/29/2023 and .should be posted daily .
- Potential for harm · D2023-09-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 track behaviors and monitor for side effects of psychotropic medications for 1 resident (Resident #38) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Behavioral Assessment, Intervention and Monitoring, last reviewed 10/2022, showed .Behavioral symptoms will be identified using facility-approved behavioral screening tools .The nursing staff will identify, document .specific details regarding .behavior .including .frequency of behavioral symptoms .behavior will be documented .When medications are prescribed .monitoring for .adverse consequences .document .worsening in the individual's behavior, mood .New .symptoms will be documented . Resident #38 was admitted to the facility on [DATE] with diagnoses to include Wedge Compression Fracture of Vertebra, Paraplegia, Atrial Fibrillation, Mood Disorder, and Congestive Heart Failure (CHF). Review of an admission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-20 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, and interview, the facility failed to follow a physician's order for 1 resident (Resident #10) to obtain a Prothrombin Time/International Normalized Ratio (PT/INR-blood test which shows how long it takes for your blood to clot) of 2 residents reviewed for PT/INR laboratory test. The findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses to include Cerebrovascular Disease, Type 2 Diabetes, Atrial Fibrillation, and Long-Term Use of Insulin. Review of a comprehensive care plan, revised 6/3/2022, showed Resident #10 was on anticoagulant therapy related to the diagnosis of Atrial Fibrillation with interventions including .Labs [laboratory] as ordered. Report abnormal lab results to the MD [Medical Doctor] .[Resident #10] on medication for Atrial Fibrillation r/t [related to] CEREBROVASCULAR DISEASE .See med [medication] focus care plan .Labs as ordered by physician . Review of a comprehensive care plan, revised 8/13/2022, showed Resident #10…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-12-04 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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, and interview, the facility failed to prevent abuse for 1 resident (#7) of 14 residents reviewed for abuse. The findings include: Review of the facility policy, Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy, undated, revealed .resident has the right to be free from abuse .Resident's must not be subjected to abuse by anyone .including, but is not limited to .other residents .the facility's goal is to protect the resident from abuse .The facility has developed and implemented written policies and procedures designed to prohibit and prevent mistreatment .and abuse of residents . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, Dementia, Parkinson's, Seizure Disorder, Anxiety, and Schizophrenia. Medical record review of Resident #7's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident scored a 14 on the Brief Interview for Mental Status (BIMS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-12-04 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to update the care plan to reflect a preference for Do Not Resuscitate status for 1 resident (#40) of 24 residents reviewed for Advanced Directives. The findings include: Medical record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Congestive Heart Failure, Dementia, Bipolar Disorder, Dysphagia, and Severe Protein-Calorie Malnutrition. Medical record review of the POST (Physician's Orders for Scope of Treatment) form dated [DATE] revealed .Do Not Attempt Resuscitation . Medical record review of the current Comprehensive Care Plan revealed .CPR [Cardiopulmonary Resuscitation] . Interview with the Director of Nursing (DON) on [DATE] at 1:54 PM, on the A Hallway, confirmed it was her expectation for .care plans to be updated the next day or the following Monday .if occurred on a weekend .we like to discuss as a team .
- Potential for harm · D2019-12-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain oral care for 1 resident (#108) of 24 residents reviewed. The findings include: Review of the facility policy, ORAL HYGIENE, revised 8/25/14 revealed .PURPOSE .To cleanse the mouth, teeth, and dentures .To moisten the mucous membranes .Oral hygiene to meet the resident's needs .Inspect mouth and gums for irritation or open areas and notify charge nurse .DOCUMENTATION .Condition of mouth and gums . Medical record review revealed Resident #108 was admitted to the facility on [DATE] with diagnoses including Toxic Encephalopathy, Epilepsy, Diabetes, Dysphagia, and Gastrostomy Status. Medical record review of the Nurse's Note dated 11/25/19 revealed the resident was total care for Activities of Daily Living (ADL's). Medical record review of the admission assessment dated [DATE] revealed Resident #108's skin integrity was normal, had their own teeth, and the tongue, cheeks, and lips were pink. Medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-12-04 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to properly label an enteral feeding for 1 resident (#40) of 2 residents reviewed with an enteral feeding. The findings included: Review of the facility policy, ENTERAL FEEDING, dated August 25, 2014, revealed .check the enteral nutrition label against the order .Check the following .Resident name, ID and room number .Type of formula .Date and time formula was prepared .Rate of administration (mL [milliliters]/hour) . Medical record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Congestive Heart Failure, Dementia, Bipolar Disorder, Dysphagia, and Severe Protein-Calorie Malnutrition. Medical record review of the Annual Minimum Data Set (MDS) dated [DATE] revealed the resident received tube feeding. Medical record review of the Physician's Orders dated 11/24/19 revealed .at bedtime 4 cans of 2 Cal [tube feeding formula] for 12 hr [hour] @ [at]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-10-17 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, medical record review, observation, and interview, the facility failed to assess for restraint usage of 1 resident (#47) of 24 residents sampled. The findings include: Review of the facility's Physical Restraints policy dated 8/18/05 revealed .the restraint assessment is completed to ensure the least restrictive device is used and notification is documented; and c. the Physician order is written to include the type of restraint, when to use, reason for usage, and continuous monitoring information (30 minute checks and 2 hour releases) . Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Vascular Dementia with Behavioral Disturbance, Dysphagia, Major Depressive Disorder, Anxiety, and Traumatic Subdural Hemorrhage. Medical record review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #47 had moderate cognition impairment, and required maximum assistance of 2 staff for all activities…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-10-17 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and interview, the facility failed to submit a PASSR (Preadmission Screening and Resident Review) Level II evaluation after completion of a Significant Change Minimum Data Set (MDS) for 1 resident (#55) of 7 residents reviewed for PASSR Level II evaluation. The findings include: Medical record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Unspecified Dementia with Behavioral Disturbance, Schizophrenia, Generalized Anxiety Disorder, Major Depressive Disorder, and Moderate Intellectual Disabilities. Medical record review revealed a PASSR Level I approval evaluation dated 2/6/07. Medical record review of the Significant Change MDS dated [DATE] revealed the facility responded 'no' to the resident having serious mental illness and/or intellectual disability or a related condition. Further review revealed a Brief Interview of Mental Status (BIMS) of '3' indicating severe cognitive impairment and verbal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2018-10-17 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to revise a care plan for pressure ulcers for 1 (#60) resident of 2 residents reviewed for pressure ulcers of 24 residents sampled. The findings included: Review of the facility policy, Skin Care Process, dated 1/17/18 revealed, .Developing and implementing an individualized plan of care .Evaluating the effectiveness of the plan of care and revising approaches as needed . Medical record review revealed Resident #60 was readmitted to the facility on [DATE] with diagnoses including Acute Kidney Failure, Chronic Kidney Disease, Diabetes, Morbid Obesity, Hypothyroidism, and Superficial Mycosis. Medical record review of the Daily Skilled Nurses Notes dated 10/13/18 revealed .excoriation to buttocks/upper thighs bilat with tx (treatment) in progress . Medical record review of a Anatomical Location Guide dated 10/14/18 revealed open area 6 x 6 back left thigh and open area 6 x 6 back right buttock and upper back 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.
- Potential for harm · D2018-10-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to document a complete assessment of pressure ulcers and notify the Physician timely for 1 resident (#60) of 2 residents reviewed for pressure ulcers of 24 residents sampled. The findings included: Review of the facility policy, Skin Care Process, dated 1/17/18 revealed, .Registered Nurse .Stages pressure wounds .Observes wounds weekly. May be responsible for measuring and documenting the progress of the wound .Licensed Practical Nurse .Provides treatment according to physician's orders .may measure and document progress of wounds if trained and competent in wound evaluation .Documentation should include, but is not limited to, regular skin inspections, pressure wound measurements and progress .when documenting, it is important to include the location of the wound, presence of exudate, pain, signs of infection, and the wound bed characteristics . Medical record review revealed Resident #60 was readmitted to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to COMMUNITY ELDERCARE SERVICES — 17 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.0 | -1.0 vs chain |
| Health inspection | 1 of 5 | 2.3 | -1.3 vs chain |
| Staffing | 2 of 5 | 3.2 | -1.2 vs chain |
| Quality measures | 3 of 5 | 1.8 | +1.2 vs chain |
The other 16 homes this chain runs (chain average 2.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| COMMUNITY ELDERCARE SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 04/17/2017 |
| LAWRENCE, RICHARD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/25/2025 |
| WAKHAM, MANCEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/03/2017 |
CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 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 23% 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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Tennessee Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 445223. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-09-20, 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 →
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