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Hartsville Convalescent Center

649 McMurry Blvd, Hartsville, TN 37074 · For profit - Corporation · 95 certified beds · (615) 374-9144 Medicare & Medicaid certified

Call the home — (615) 374-9144 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$16,796 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

Worth asking about
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $16,796 in federal fines (most recent 2025-08-11)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (72%) runs well above the national median (45%)
  • its last standard health inspection was over 2 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 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
715 McMurry Blvd E · (615) 551-4216 · Call to confirm hours
Pharmacy
Walgreens0.9 mi
210 McMurray Boulevard · (615) 374-2438 · Call to confirm hours
Grocery
711 McMurry Blvd E · (615) 374-9003 · Call to confirm hours
Park
265 Marlene St · (615) 374-1129 · Typically dawn to dusk
Place of worship
616 McMurry Blvd · (615) 374-9700

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 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

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

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased27.5%14.0%15.4%worse
Long-stay residents who lose too much weight5.2%6.1%5.4%typical
Long-stay residents with a catheter left in their bladder1.5%0.7%0.9%worse
Long-stay residents with a urinary tract infection1.7%1.8%2.0%better
Long-stay residents with depressive symptoms5.9%13.8%6.5%typical
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.6%3.4%3.3%better
Long-stay residents whose ability to walk worsened21.4%17.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication31.7%31.7%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers6.3%5.0%4.7%worse
Long-stay residents with worsening bladder/bowel control10.9%20.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table23.7%16.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.9%1.7%1.4%worse
Short-stay residents given the seasonal flu vaccine76.6%79.8%79.4%typical
Short-stay residents rehospitalized after admission13.0%22.6%22.6%better
Short-stay residents with an outpatient ER visit18.2%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.111.671.67better
Long-stay outpatient ER visits per 1,000 resident days1.281.561.80better

§ 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.

49.9% 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 60 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.9%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
38.1%U.S. median 56.6%
Met the expected recovery
0.36U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 38.1% 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 21 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 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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 SNF49.9%CMS range 38.8–59.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 6.6–15.310.7%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 discharge38.1%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 discharge28.6%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 discharge33.3%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 identified96.9%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — 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 stay3.1%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 worsened3.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.6%CMS range 4.2–13.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.161.02Oct 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

<0.01
RN hours/ resident / day
3.69
LPN hours/ resident / day
1.95
Aide hours/ resident / day
5.64
Total nurse hours/ resident / day
0.01
RN hoursweekends
72.3%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 95 beds and averages 51.6 residents a day — about 54% occupied, or roughly 43 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 5.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.00 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.95 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 4.64 hrs/resident/day on weekends vs 6.05 on weekdays — 23% thinner on weekends — a notable drop. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 72% 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

7
deficiencies at the latest standard inspection (2024-07-18)
7
at the previous standard inspection (2020-01-15)

Deficiencies are unchanged from the previous inspection. 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 2 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.

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-08-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, facility investigation review, medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent 1 of 6 (Resident #1) residents reviewed for wandering behaviors from exiting the building without staff supervision. Resident #1 was a vulnerable, cognitively impaired Resident with a history of wandering behaviors and wore a wander guard on his person and on his wheelchair. On 10/28/2024, an order was written to discontinue the wander guard from Resident #1's wheelchair. The facility discontinued Resident #1's wander guard from his wheelchair and from his person. Resident #1 eloped from the facility on 11/27/2024, 29 days after the wander guard was discontinued from his wheelchair and his person. The facility's failure to ensure a safe, secure environment resulted in Immediate Jeopardy (IJ) when Resident #1, eloped from the facility on 11/27/2024, and was found approximately 0.3 miles from the facility at a discount retail store.…

    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 · Past Non-Compliance
  • Potential for harm · Fcited before2024-07-18 · 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

    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 ensure food was stored, prepared, and served under sanitary conditions as evidenced by unlabeled and undated food items, failed to maintain 1 of 2 coolers in proper working order to prevent potential cross-contamination to stored food, and failed to keep a temperature log and a thermometer for all personal refrigerators for 4 of 4 (Resident #2, #3, #11, and #42) sampled residents reviewed. The facility had a census of 53. The findings include: Review of the facility policy titled, Food Receiving and Storage, dated 10/2017 revealed, .All foods stored in 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 and documented according to state-specific requirements . Review of the facility policy titled, Maintenance Service,…

    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 · D2024-07-18 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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, hospital record review, medical record review and interview, the facility failed to provide the resident with a notice of the bed hold policy for 5 (Resident #4, Resident #31, Resident #41, Resident #46 and Resident #155) of 5 residents reviewed. The findings included: Review of the undated policy titled Bed Hold Policy revealed When a resident goes to the hospital from Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF), Medicaid/Medicare will not pay to hold the bed in the nursing home. If a resident or resident's representative (RR) wants to hold their bed as Private Pay while they are in the hospital, the Business Office must be notified immediately to decide. The charges for the bed hold will begin the day the resident is transferred to the hospital. If a resident .or their RR, does not make the arrangements as described above, they will be discharged , and all items will be boxed and placed in storage for a limited time .To ensure that the resident and/or…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-18 · tag F0644 — isolated
    Coordinate 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 facility policy review, medical record review, and interview, the facility failed to ensure a new Pre-admission Screening and Resident Review (PASARR) screen was completed after an identified mental health diagnosis for 2 of 5 sampled residents (Resident #41 and Resident #47) reviewed. The findings include: Review of the facility policy titled, Resident Assessment-Coordination with PASARR Program, dated 6/2024 revealed, .This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder .or a related condition receives care and services in the most integrated setting appropriate to their needs .PASARR Level I - initial pre-screening that is completed prior to admission .Negative Level I Screen - permits admission to proceed and ends that PASARR process unless a possible serious mental disorder .arises later .Positive Level I Screen - necessitates a PASARR Level II evaluation prior to 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-18 · 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, facility fall investigation review, medical record review, and interview the facility failed to implement a comprehensive person-centered care plan intervention for 1 of 8 (Resident #39) sampled residents reviewed for falls. The findings include: Review of the facility policy titled, FALL PREVENTION AND MANAGEMENT, dated 10/2023 revealed, .A Fall Prevention and Management Program is used to provide a safe environment for residents. This program is designed to identify residents at risk of falls; define interventions for the prevention of falls and/or decrease the likelihood of injury .Nursing Management is responsible for updating care plan related to fall risk, interventions and/or injury related to falls .Review and update causative factors, interventions, and care plan .Pattern of falls, when identified, should be thoroughly evaluated for underlying causes so that a proactive approach and interventions can be implemented to decrease likelihood of further falls . Review of the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, facility fall investigation review, medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent an accident for 1 of 8 (Resident #39) sampled residents reviewed for accidents. The findings include: Review of the facility policy titled, FALL PREVENTION AND MANAGEMENT, dated 10/2023 revealed, .A Fall Prevention and Management Program is used to provide a safe environment for residents. This program is designed to identify residents at risk of falls; define interventions for the prevention of falls and/or decrease the likelihood of injury .Nursing Management is responsible for updating care plan related to fall risk, interventions and/or injury related to falls .Review and update causative factors, interventions, and care plan .Pattern of falls, when identified, should be thoroughly evaluated for underlying causes so that a proactive approach and interventions can be implemented to decrease likelihood of further falls . Review 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-18 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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 interviews the facility failed to provide evaluation and rational for continued use of a PRN (as needed) anti-anxiety medication for 1 resident (Resident #47) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Psychotropic Medication Use, dated 12/2023 revealed, .Residents of the facility who are prescribed a psychotropic medication will be monitored. The resident ' s need for the psychotropic medication will be monitored .Both the medical staff and nursing shall evaluate the effectiveness of PRN orders for psychotropic drugs to manage behavior . Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses which included Acquired absence of left leg above knee, Chronic Obstructive Pulmonary Disease, and Peripheral Vascular Disease. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-18 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 53 rooms observed. The facility failed to provide clean equipment for 1 of 53 (Resident #155) sampled residents reviewed. The findings include: Review of the facility policy titled, Disinfection of Bedpans and Urinals, dated 1/16/2024, revealed .Bedpans and urinals are handled in a manner to prevent the spread of infection through personal equipment .Bedpans and urinals are for single resident use only. [NAME] with the resident's name and discard upon discharge .Store bedpans and urinals in the resident's bedside cabinet or drawer after placing in a plastic bag or as per facility policy . Review of the facility's policy titled, Guidelines for the Administering and Storage of Oxygen, revised 10/2023, revealed .Oxygen is administered for adults through an…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2020-01-15 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility documentation review, observation and interview, the facility failed to store food in a safe and sanitary manner as evidenced by unlabeled, undated and expired food in the walk-in refrigerator, walk-in freezer and the kitchen dry bin. The Findings include: Facility document review, Untitled, Dated 1/2020, revealed .all food items are monitored for expiration dates and discarded when they expire . Observation and interview on 1/13/2020 at 9:00 AM with the Dietary Manager in the freezer confirmed 4 large bags of creamed corn expired 8/28/18, ½ bag of zucchini unlabeled and undated; 4 bags (2 lb) fried green tomatoes undated; 1 bag french style bread unlabeled and undated and 1 partially used bag of garlic knots unlabeled and undated. Continued interview in the Walk-In Refrigerator confirmed 1 container of chicken salad (5 lb) opened and undated. Observation and interview on 1/14/2020 at 4:45 PM in the kitchen with the Dietary Manager confirmed the following in the dry storage bin: 1 partially used bag of cornmeal expired on 10/25/19; 8 bags of cornmeal (5lb) expired…

    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 · E2020-01-15 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY wBased on medical record review, facility documentation review and interview, the facility failed to complete a Quarterly (once every 3 months) Minimum Data Set (MDS) assessment for 20 (#2, #5, #7, #9, #11, #12, #13, #14, #17, #20, #21, #74, #76, #124, #126, #224, #225, #230, #231 and #276) of 40 resident Quarterly assessments reviewed. The findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes, Vascular Dementia With Behavioral Disturbances, Chronic Kidney Disease and Anxiety Disorder. Facility document review revealed Resident #2's Quarterly MDS assessment was due on 11/7/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #2 on 11/7/2019. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Heart Failure, Chronic Kidney Disease and Hypertension. Facility document review revealed Resident #5's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-15 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation and interview, the facility failed to treat 1 (#229) of 1 resident who required a urinary catheter with dignity related to not covering the resident's catheter drainage bag. The findings include: Review of the facility policy, Resident Rights Policy dated 12/2019, revealed .The resident has the right to a dignified existence, self- determination, and communication with access to persons and services inside and outside the facility . Medical record review revealed Resident #229 was admitted to the facility on [DATE] with diagnoses which included Benign Prostatic Hyperplasia with lower Urinary tract symptoms and Retention of Urine. Medical record review of the 5 day Minimum Data Set (MDS) dated [DATE] revealed Resident #229 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. Continued review revealed Resident #229 required an indwelling catheter. Medical record review of Resident #229's physician…

    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
Show the remaining 16 citations
  • Potential for harm · D2020-01-15 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, facility documentation review and interview, the facility failed to complete an Annual Minimum Data Set (MDS) assessment for 1 (#125) of 40 resident assessments reviewed. The findings include: Medical record review revealed Resident #125 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes, Dementia With Behavioral Disturbances, Chronic Kidney Disease, and Peripheral Vascular Disease. Facility document review revealed Resident #125's Annual MDS assessment was due on 12/15/2019 and was not completed. Medical record review revealed no Annual MDS assessment completed for Resident #125 on 12/15/2019. Interview with the MDS Coordinator on 1/14/2020 at 4:45 PM in the MDS office confirmed no Annual MDS assessment had been completed for Resident #125.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-15 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews, the facility failed to develop a comprehensive care plan for 1 ( #274)of 40 residents reviewed. The findings include: Medical record review revealed Resident #274 was admitted to the facility on [DATE] with diagnoses which included Dementia without Behavioral Disturbances, Osteoarthritis and Diverticulosis of Large Intestine. Medical record review of the 5 day Minimum Data Set (MDS) dated [DATE] revealed Resident #274 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated severe cognitive impairment. Medical record review revealed no comprehensive care plan was developed for Resident #274. Interview with the Assistant Director of Nursing (ADON) on 1/15/2020 at 1:35 PM in the conference room revealed the floor nurses were responsible for completion of the interim care plan and the the MDS coordinator was responsible for completion of the comprehensive care plans. Interview with the MDS Coordinator on 1/15/2020 at 1:52 PM in the MDS office confirmed…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-15 · tag F0727 — failed to provide required RN coverage — isolated
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on facility policy review, facility documentation review and interview, the facility failed to have 8 hours of Registered Nurse (RN) coverage on 11/10/2019 for 1 of 73 days reviewed. The findings include: Review of the undated facility policy, RN Coverage revealed .This centers recognizes CMS [Centers for Medicare Services] requiring RNs 7 days a week and has stringently attempted to maintain that standard . Facility documentation review of the daily staffing census dated 11/10/2019 revealed the RN worked 4 regular hours. Facility documentation review of the nursing staff time punches dated 11/10/2019 revealed the RN worked 6 regular hours. Interview with the Assistant Director of Nursing (ADON) also known as the scheduler on 1/15/2020 at 1:35 PM in the conference room confirmed the facility had RN coverage for 6 hours on 11/10/2019. Interview with the Administrator on 1/15/2020 at 6:04 PM in the conference room confirmed there were not any RN's to cover the 8 hours on November 10th.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation and interview, the facility failed to provide a sanitary environment to help prevent the development and transmission of infection for 4 (#10, #18, #230 and #275) of 6 residents during the noon meal on 1/13/2020. The findings include: Facility policy review, Infection Control Policy, undated, revealed .the facility has established and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment. The infection control program is designed to help prevent development and transmission of disease and infection . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Chronic Diastolic Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia and History of Pneumonia. Medical record review of Resident #10's 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2018-12-12 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, facility documentation review and interview the facility failed to ensure a Registered Nurse (RN) was present in the facility at least 8 hours a day 7 days a week for 38 days from 12-1-17 through 12-10-18 (374 days). The findings include: Review of an undated facility policy, RN (Registered Nurse) Coverage, revealed .This center recognizes CMS (Centers for Medicare and Medicaid Services) requiring RNs 7 days a week . Review of the daily staffing schedules from 12-1-17 through 12-10-18 revealed the facility did not have RN coverage for 38 days of 374 days with 32 of these as weekend days (12-1-17, 12-2-17,12-10-17, 12-16-17, 12-17-17, 12-22-17, 12-29-17, 1-13-18, 1-14-18, 3-11-18, 3-24-18, 4-7-18, 4-21-18, 4-22-18, 5-5-18, 5-6-18, 5-19-18, 5-20-18, 6-2-18, 6-3-18, 6-17-18, 6-30-18, 7-1-18, 7-14-18, 7-15-18, 8-26-18, 9-8-18, 9-9-18, 9-22-18, 9-23-18, 10-2-18, 10-6-18, 10-7-18, 11-4-18, 11-17-18, 11-18-18, 12-1-18, and 12-2-18). Interview with the Staffing Coordinator/Assistant Director of Nursing on 12/12/18 at 8:46 AM in her office confirmed she was…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2018-12-12 · tag F0758 — failed to limit and justify psychotropic drugs — widespread
    Implement 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 have a stop date for 5 residents (#9, #26, #29, #30, and #47) after 14 days for PRN (as needed) antipsychotic and psychotropic medications and failed to monitor side effects and behaviors for 30 residents (#1, #2, #3, #4, #5, #8, #9, #12, #13, #14, #17, #18, #20, #21, #23, #26, #29, #30, #31, #34, #35, #36, #37, #38, #40, #41, #43, #47, #48, #49) of 33 residents reviewed. The findings include: Review of the facility policy dated 12/7/18, Psychotropic Medication Use, revealed .PRN [as needed] orders for psychotropic drugs should be limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order .PRN orders for antipsychotic drugs should be limited to 14 days and should not be renewed unless the attending physician…

    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 · F2018-12-12 · tag F0802 — failed to prepare enough nourishing food — widespread
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility dietary department failed to dispose of expired food; failed to serve cold food at or less than 41 degrees Fahrenheit (F); failed to maintain equipment and serving utensil in a sanitary manner; and failed to operate the dish machine per manufacturer's recommendation, revealed the dietary department staff did not show competency and skill set to safely carry out the functions of the dietary department in 3 of 6 observations. The findings include: Interview with the Dietary Manager on 12/10/18 at 8:50 AM in the dietary department revealed the Dietary Manager was hired on 9/24/18 and was not a Certified Dietary Manager (CDM) but was enrolled in the correspondence course to become a CDM. Observation and interview on 12/10/18 at 8:50 AM, with the Dietary Manager present, in the dietary department walk-in refrigerator revealed a 5 pound commercial container of egg salad with the expiration date of 11/17/18 and was available for use. Observation on 12/10/18 at 12:08 PM in the dietary department revealed the resident mid-day meal trayline was…

    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 · Fcited before2018-12-12 · 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 observation, review of the dish machine manufacturer's recommendation, review of the dish machine operation log, and interview, the facility dietary department failed to dispose of expired food; failed to maintain equipment in a sanitary manner; failed to store serving utensils in a sanitary manner; and failed to operate the dish machine according to the manufacturers recommendation for 3 of 6 dietary department observations. The findings include: Observation and interview on 12/10/18 at 8:50 AM, with the Dietary Manager present, in the dietary department walk-in refrigerator revealed a 5 pound commercial container of egg salad with the expiration date of 11/17/18 was available for service. Interview with the Dietary Manager confirmed the egg salad was past the expiration date and needed to be removed and disposed of on 11/18/18. Observation and interview on 12/10/18 at 12:30 PM, with the Dietary Manager present, in the dietary department revealed 2 pieces of equipment on a production counter covered with plastic. Interview with the Dietary Manager revealed the plastic…

    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 · E2018-12-12 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility dietary department failed to serve cold food, for resident meals, at or less than 41 degrees Fahrenheit (F) in 1 of 2 meals observed. The findings include: Observation on 12/10/18 at 12:08 PM in the dietary department revealed the resident mid-day meal trayline was in operation and the residents in the dining room had been served the mid-day meal. Observation revealed the dietary cook obtaining the food temperatures on the trayline. Further observation revealed the cottage cheese on the peaches was 52.5 degrees F and the milk stored on a thin layer of ice in a plastic container was 42.9 degrees F. Further observation revealed the trayline resumed operation and the cottage cheese with peaches and milk were placed on the residents' trays and the trays for the 200 hall were placed into the meal delivery cart. Interview with the Dietary Manager on 12/10/18 at the time of the observation confirmed the cottage cheese with the peaches and milk were placed in the meal delivery cart for the 200 hall and the food temperatures were not served 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2018-12-12 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation and interview, the facility failed to maintain infection control due to staff failing to use Personal Protective Equipment while administering an injection for 1 resident (#11) of 9 residents reviewed. The facility failed to date and maintain oxygen/nebulizer equipment in a sanitary manner for 5 residents (#30, #35, #43, #47, #48) of 7 residents receiving respiratory treatment. The findings include: Review of an undated facility policy, Infection Prevention Standards, revealed .Gloves are to be worn and changed between patients . Review of an undated facility policy, Oxygen Administration, revealed .At regular intervals, check and clean oxygen equipment, masks, tubing and cannula . Observation on 12/10/18 at 12:24 PM at the 200 Hall nurses station revealed Registered Nurse (RN) #2 administered an insulin injection without wearing gloves. Interview with RN #2 on 12/10/18 at 12:25 PM at the 200 Hall nurses station revealed gloves were to be worn…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2018-12-12 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, the facility failed to provide dignity for 1 of 18 residents (#30) being served a meal tray during the noon meal. The findings include: Medical record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia with Behavioral Disturbances, and Memory Deficit following Cerebrovascular Disease. Medical record review of the admission Minimum Data Set, dated [DATE] revealed Resident #30 required extensive assist with one person physical assist with eating. Observation on 12/10/18 at 12:19 PM in the main dining room revealed Resident #30 sitting at a table with Resident #34. Further observation revealed Resident #34 received a meal tray at 12:19 PM and Resident #30 received a meal tray at 12:28 PM after 14 other residents in the dining room were served their meal trays. Interview with Certified Nursing Technician #1 on 12/10/18 at 12:30 PM in the main dining room revealed Resident #30 sits at the table 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-12-12 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 and interview, the facility failed to follow the physician's order for a nebulizer treatment for 1 (#47) of 7 residents receiving respiratory therapy. The findings include: Medical record review revealed Resident #47 was admitted to the facility on [DATE], was discharged to the hospital on [DATE], and readmitted to the facility on [DATE] with diagnoses included Chronic Respiratory Failure with Hypercapnia, and Cardiovascular Disease. Medical record review of a Physician Order dated 10/26/18 revealed Duoneb inhaler (respiratory treatment) 3 ml (milliliters) q 6 hr (every 6 hours). Further review of a Telephone Physician Order dated 11/27/18 revealed Ipratropium-Albuterol (Duoneb) inhalation 0.5-3mg (milligrams) (2.5mg base)/3ml, 1 vial, q 4 hr PRN (as needed). Medical record review of the December 2018 recapitulation Physician Order, not signed by the physician, revealed the Duoneb 0.5-3milligram (mg)/3 Ampul-Neb 1 unit dose nebulizer Tx (3ml) every 6 hours with the notation 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 · D2018-12-12 · tag F0711 — isolated
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to have physician orders signed in a timely manner for 7 residents (#5, #20, #21, #39, #43, #1, and #2) of 51 records reviewed. The findings included: Medical record review revealed Resident #5 was readmitted , after a hospitalization, to the facility on 1/2/19 with diagnoses which included Dementia with Behavioral Disturbance, Psychotic Disorder with Hallucinations, Mood Disorder with Depressive features, Alzheimer's Disease, and Insomnia. Medical record review of the Physician Telephone Orders for Resident #5 revealed the following orders were not signed by physician services: On 1/21/19 - 1) Ativan (antianxiety medication) 1 mg (milligram) SL (sublingually) every (Q) hrs (hours) as needed (PRN) for agitation. 2) Morphine (pain medication) 4 mg SL Q 6 hours (hrs) PRN for pain. 3) Atropine 1% (percent) gtts (drops) give 4 gtts SL Q 15 minutes PRN for secretions. On 1/29/19 - DC (Discontinue) PPD (tuberculin test) lab ordered. On 1/29/19 - .DC…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-12-12 · tag F0712 — isolated
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    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 ensure physician orders were signed since 10/2/18 for 2 (#47, #10) of 37 residents reviewed. The findings include: Review of an undated facility Physician Services Policy, revealed .Frequency of physician visits - Each res [resident] shall be seen by a physician at least once every 30 days for the first 90 days after admission. Physician visits must be at least once every 60 days thereafter. A physician visit is considered timely if it occurs no later than 10 days after the date the visit was required .All required physician visits will be made personally by the physician unless this task has been delegated to a duly authorized individual under Federal and State regulations. After the initial visit, at the option of the physician, visits may alternate between the physician and a physician assistant, nurse practitioner and or clinical nurse specialist . Medical record review revealed Resident #47 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-12-12 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on facility policy review, observation and interview, the faciliy failed to properly secure and store 2 of 3 oxygen tanks at the 200 Hall nurses station. The findings include: Review of an undated facility policy, Oxygen Storage, revealed, .Cylinders for this center are stored in the basement and must be secured in racks or by chains . Observation on 12/10/18 at 10:00 AM, 12:15 PM, 1:00 PM and 2:50 PM, revealed two unsecured oxygen tanks sitting on the floor behind the nurses desk on 200 Hall. Interview with Registered Nurse #2 on 12/10/18 at 2:50 PM at the 200 Hall nurses station revealed .oxygen tanks are kept at the nurses desk in case a resident needs it, when the tank gets empty they just sit there until someone comes to pick it up and takes it to storage. Interview with the Director of Nursing on 12/10/18 at 2:58 PM in her office stated.the portable oxygen tanks are kept at the nurses station for the residents . When asked how the oxygen tanks were stored when not in use she stated, .They are stored downstairs in the storage room .

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2018-12-12 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on policy review, observation and interview, the facility failed to post the total number of licensed and unlicensed nursing staff directly responsible for resident care each shift for 3 of 3 days during the survey. The findings include: Review of an undated facility policy, Posting Daily Nurse Staffing, revealed .This center will post daily nurse staffing per CMS (Centers for Medicare and Medicaid Services) and the State of Tennessee requirements . Observation on 12/10/18, 12/11/18 and 12/12/18 of the posted daily staffing sheets posted in front of the Director of Nurse's (DON) office revealed no posting of the total number of staff responsible for resident care. Interview with the DON on 12/12/18 at 7:33 AM in her office confirmed she did not post the number of staff on the daily posting sheet. She stated I don't post the numbers, just the staff.

    Nursing and Physician Services 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

$16,796 in federal fines across 2 penalties.

  • $8,281 — penalty dated 2025-08-11
  • $8,515 — penalty dated 2024-07-18

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 / managerTypeRoleShareSince
ESTATE OF ROBERT M. BECHTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 02/17/2026
BECHT, SCOTTIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/1990
HANSON, THERESAIndividualCORPORATE OFFICER; ADP OF THE SNFsince 04/25/2025
MIDCARE, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2014
HALL, ALANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/17/2026
ROBERTSON, GEORGEIndividualADP OF THE SNFsince 02/17/2026

CMS files one row per role, so the 10 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$4.1M
Net patient revenuemost recent cost report
-14.4%
Operating marginrevenue minus expenses
$657K
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 12%Other / private 25%

This home reported $657K paid to related parties — landlords or management companies under common ownership — equal to about 14% 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

$322per resident / day
operating cost
$9,784per month
≈ monthly operating cost
$281per 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 445256. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-18, 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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