Lewis Park Post Acute

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

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

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

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

51.8% 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 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 47.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 40 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 0.33 therapist hours per resident per day in 2026Q1 — more than 55% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 131 beds and averages 80.8 residents a day — about 62% occupied, or roughly 50 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 3.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.96 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 3.80 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.36 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below 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.

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 19 most serious are shown; the remaining 9 are one tap away and print in full.

• Immediate jeopardy · Jcited before2023-11-15 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, Post-Acute Care Network Participation Agreement review, Virtual Rapid Response Telecommunication (VRRT- a teleconference between the facility and hospital about a resident's status) Recommendation Standard Operating Procedure (SOP) review, facility protocol review, medical record review, and interview, the facility failed to ensure residents' right to be free from neglect for 1 of 3 (Resident #1) sampled residents reviewed for abuse/neglect. The facility's failure to ensure a resident's right to be free from neglect resulted in Immediate Jeopardy (IJ) when on [DATE], Resident #1 developed a temperature of 106.7 degrees Fahrenheit (Hyperpyrexia- a fever above 106.0 and is considered a medical emergency), a heart rate of 131, a blood glucose of 600 (normal 70 -100). The facility contacted the VRRT on [DATE] and Resident #1 was not transferred to a higher level of care (acute care hospital) for evaluation of a medical emergency. A head-to-toe assessment was not documented as being…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-11-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, Post-Acute Care Network Participation Agreement review, Virtual Rapid Response Telecommunication (VRRT) Recommendation Standard Operating Procedure (SOP) review, facility protocol review, medical record review, TN Board of Nursing Position Statements and interview, the facility failed to ensure residents received treatment and care based on assessments, in accordance with policies, and protocols/agreements, and failed to promptly intervene for an acute change in a resident's condition for 1 of 3 (Resident #1) sampled residents reviewed for quality of care. The facility's failure to ensure a resident received appropriate assessments and interventions resulted in Immediate Jeopardy when on [DATE] Resident #1 developed a temperature of 106.7 degrees Fahrenheit (hyperpyrexia - a temperature greater than 106 and considered a medical emergency), a heart rate of 131 beats per minute (normal 60 -100), and a blood glucose level of 600 milligrams/deciliter (mg/dl) (normal 70 -100).…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-09-26 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, personnel file review, medical record review, observation and interview, the facility failed to ensure residents were not physically abused for 2 of 4 sampled residents (Resident #1 and #2) reviewed for abuse. The facility's failure to ensure a resident's right to be free from abuse resulted in Immediate Jeopardy when Registered Nurse (RN) #1 physically struck Resident #1 and forcefully took him down to the ground, and Resident #3 physically struck Resident #2 multiple times in the jaw and neck resulting in a lacerated lip. On 8/13/2023, Resident #3, with a diagnosis of Traumatic Brain Injury, physically struck Resident #2, a wheelchair bound and incomplete quadriplegic, three times in the face and neck, resulting in jeopardy with harm when Resident #2 sustained a laceration injury to his lip. Residents #2 and #3 had a known history of previous verbal altercations and on 8/13/2023 a physical altercation with each other when Resident #3 struck Resident #2 in the back. On 8/28/2023,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-09-26 · tag F0741 — failed to have staff trained for behavioral health — isolated
  Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health 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 policy review, job description review, facility assessment review, medical record review, observation, and interview, the facility failed to ensure staff had specific knowledge, sufficient competencies and skill sets necessary to provide appropriate care and services to 3 of 4 sampled residents (Resident #1, #2 and #3) with behavioral and mental health needs. Fourteen (14) facility staff including Certified Nursing Assistants (CNAs), Licensed Practical Nurses (LPN), Housekeeping Personnel, and a Registered Nurse failed to demonstrate appropriate interventions were implemented to prevent ongoing altercations between Resident #2 and #3, with a history of verbal and physical altercations. On 8/13/2023 at 12:58 PM, and at 5:00 PM, Residents #2 and #3 had verbal altercations, the staff separated the residents, and then left them unsupervised. Eventually on 8/13/2023 at 5:45 PM, Residents #2 and #3 had another altercation where Resident #3 struck Resident #2 multiple times, which resulted in a laceration 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-06-01 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation and interview, the facility failed to ensure residents' right to be free from verbal, physical, and sexual abuse for 3 of 12 sampled residents (Resident #14, #60, and #71) reviewed for abuse. The facility's failure to ensure a resident's right to be free from abuse resulted in Immediate Jeopardy when the facility failed to identify an incident of resident-to-resident verbal abuse (Resident #269 and Resident #60), an incident of resident to resident sexual/physical abuse (Resident #269 and Resident #14), an incident of resident to resident physical abuse (Resident #269 and Resident #60), and an allegation of resident to resident sexual/physical abuse (Resident #269 and Resident #71). Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Assistant Director of Nursing (ADON), the…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-06-01 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview the facility failed to report allegations of abuse for 3 of 12 (Resident #14, #60, and #71) sampled residents reviewed for abuse. The facility's failure to report allegations of sexual, physical, and verbal abuse to the State Survey Agency, law enforcement and Adult Protective Services (APS) which resulted in Immediate Jeopardy when on 8/20/2022, Resident #14 reported to staff Resident #269 ejaculated semen on his wheelchair and shirt. On 11/10/2022, Resident #60 was found by staff in a trash can in the back dining room. Resident #60 reported to staff, Resident #269 put her in the trash can. Resident #269 confirmed to staff that he put Resident #60 in the trash can. On 11/20/2022, staff witnessed Resident #269 throw a cup at Resident #60 that hit her in the face. On 11/27/2022, Resident #71 reported to staff Resident #269 touched him inappropriately on his groin area. On 12/16/2022, staff witnessed Resident #269 verbally threaten Resident #60 with…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-06-01 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review and interview the facility failed to thoroughly investigate 4 incidents of abuse for 3 of 12 sampled residents (Residents #14, #60, and #71) reviewed for physical, verbal and sexual abuse. The facility's failure to thoroughly investigate incidents of sexual and physical abuse resulted in Immediate Jeopardy when on 8/20/2022, Resident #14 reported to Licensed Practical Nurse (LPN) #3 that his roommate (Resident #269) had ejaculated on his wheelchair and shirt. The facility did not investigate or complete an incident note. On 11/10/2022, Resident #269 admitted to physical abuse by placing Resident #60 in a trash can. The facility did not thoroughly investigate by failing to interview other staff or resident to substantiated it was horseplay. On 11/20/2022, staff witnessed Resident #269 throw a cup hitting Resident #60 in the face. The facility did not thoroughly investigate the incident after Resident #60 and Resident #269 stated it was horseplay. No statements were…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-06-01 · tag F0742 — isolated
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation and interview, the facility failed to provide treatment and services to effectively manage behaviors and attain the highest practicable mental and psychosocial well-being for 1 of 10 (Resident #269) sampled residents exhibiting behaviors that included sexual, verbal, and physical behaviors. Resident #269 ejaculated on Resident #14's wheelchair and shirt, openly masturbated in common spaces in the facility, openly urinated in public common spaces in front of staff and residents, had sexual relations in room with roommate present and without privacy, touched staff inappropriately, used verbally abusive language, yelled and threw things, shoved staff against the wall, kissed staff, threw a cup hitting Resident #60 in the face, and placed Resident #60 in a trash can. The facility's failure to effectively address Resident #269's behaviors and protect all residents from those behaviors resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-06-01 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Board of Examiners of Nursing Home Administrators (BENHA) Form, the Administrator job description, the Director of Nursing Job Description, and the Assistant Director of Nursing job description, policy review, and interview, the facility Administration failed to provide oversight to ensure systems and processes were consistently followed, failed to implement policies and procedures to ensure residents were free from verbal, physical, and sexual abuse, failed to report and investigate all allegations of abuse, and failed to provide appropriate treatment and services for resident behaviors. The Administration's failure to identify, protect, investigate and report abuse allegations resulted in Immediate Jeopardy when on 8/20/2022 Resident #14 reported to a staff member that Resident #268 ejaculated on his chair and on his shirt, on 11/10/22, 11/20/2022 and 12/16/2022 staff reported that Resident #269 was physically and verbally abusive to resident #60, and on 11/27/2022 Resident #71 reported…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide 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 policy review, medical record review, observation, and interview, the facility failed to ensure that residents received the necessary treatment and services consistent with professional standards of practice to promote healing when the facility failed to stage a pressure wound upon discovery, perform weekly wound assessments, and when wound care treatments were not performed for 2 of 3 (Residents #6 and #79) sampled residents reviewed for pressure ulcers. The findings include: 1. Review of the facility policy titled, Pressure Injuries Overview, dated March 2024, revealed .Pressure Ulcer/Injury .refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical device .A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage . Review of the facility policy titled, Treat In Place/Advanced Nursing Protocols, dated 1/9/2025, revealed .It is the goal of the facility to provide safe, high quality care 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-20 · tag F0569 — isolated
  Notify 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 policy review, resident trust accounts review, medical record review, and interview, the facility failed to refund the resident's funds within 30 days of death or discharge for 1 of 2 (Resident #78) sampled residents reviewed for personal trust fund account. The findings include: Review of the undated facility policy titled, .Resident Trust Fund . revealed .Upon death or discharge of a resident with a personal fund account, the facility will convey within 30 days the resident's funds and a final accounting of those funds .to the individual or probate jurisdiction administering the resident's estate . Review of the medical record revealed Resident #78 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Malnutrition, Dysphagia, and Anxiety. Review of Resident #78's Trust Fund Statement dated 4/1/2025 through 6/25/2025, revealed Resident #78 had an account balance of $70.08. Review of the Nurse's Note dated 6/8/2025, revealed .Pronouncement of death at 6:10 AM . 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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-20 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the Resident Assessment Instrument (RAI) User's Manual review, medical record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were signed by a Registered Nurse for 7 of 18 (Resident #1, #6, #13, #23, #31, #40, and #73) sampled residents reviewed. The findings include: 1. Review of the Minimum Data Set (MDS) Resident Assessment Instrument (RAI) User's Manual dated 2023, revealed .RNAC [Registered Nurse Assessment Coordinator] An individual licensed as a registered nurse by the State Board of Nursing and employed by a nursing facility and is responsible for coordinating and certifying completion of the resident assessment instrument . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Anxiety, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #1…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-20 · tag F0757 — failed to avoid unnecessary drugs — isolated
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to ensure monitoring was conducted according to the physician's order for 1 of 5 (Resident #31) sampled residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Administering Medications, dated 4/2019, revealed .Medications are administered in a safe .manner as prescribed.Medications are administered in accordance with prescriber orders.The following information is checked/verified for each resident prior to administering medications.vital signs if necessary. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Diabetes, and Hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #31 was severely cognitively impaired. Resident #31 had a diagnosis of Hypertension. Review of the Physician's Order dated 2/24/2025, revealed Resident #31 had an order for…

  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 before2025-08-20 · 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 policy review, medical record review, observation, and interview, the facility failed to ensure the prevention and spread of infection when 1 of 17 staff (Certified Nursing Assistant (CNA) C) failed to use appropriate Personal Protective Equipment (PPE) during dining for 2 of 2 (Resident #25 and #33) sampled residents in transmission based precautions (TBP) and when 2 of 17 staff (CNA E and CNA F) failed to perform hand hygiene for 2 of 18 (Resident #6 and #40) residents observed for dining in the dining room. The findings include: 1. Review of the facility policy titled , Handwashing/Hand Hygiene, dated 10/2023, revealed .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Hand hygiene is indicated.immediately before touching a resident.after touching a resident.after touching the resident's environment.Single-use disposable gloves should be used.when in contact with a resident, or the equipment or environment of a resident, who is on contact…

  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 · D2025-08-20 · tag F0882 — isolated
  Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, Centers for Medicare & Medicaid Services guidelines, Infection Prevention Control Officer Training certificate review, and interview, the facility failed to ensure employment of a qualified Infection Control Preventionist to monitor and maintain the facility's Infection Prevention and Control Program. This could have affected 71 out of 71 residents residing in the facility. The findings include: 1. Review of the facility policy titled, Infection Prevention and Control Program, dated 12/2023, revealed .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.The IPCP is coordinated and overseen by an infection prevention specialist (infection preventionist). 2. Review of the Centers for Medicare & Medicaid Services factsheet titled, Updated Guidance for Nursing Home Resident Health and Safety, dated [DATE], revealed…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-06-06 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained for 6 of 6 sampled residents (#4, #42, #51, #66, #78 and #134) reviewed for enhanced barrier precautions and for 1 of 9 Certified Nursing Assistant (CNA) F failed to remove a urinal filled with urine from Resident #63's overbed table during dining. The findings include: 1. Review of the facility's policy titled, Transmission Based Precautions, revised date 4/1/2024 revealed, .To provide guidance on taking appropriate precautions to prevent transmission of infectious agents .Initiation of Enhanced Barrier Precautions .An order for enhanced barrier precautions shall be obtained for residents with any of the following .pressure ulcers .indwelling medical devices .feeding tubes, tracheostomy .even if the resident is not infected .Make gowns and gloves available which may include near or outside of the resident's room .face protection may also…

  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 before2024-06-06 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to provide information regarding residents' right to formulate an Advanced Directive for 5 of 24 sampled residents (Resident #1, #15, #22, #34, and #39) reviewed for Advanced Directives. The findings include: 1. Review of the facility's policy titled, Advance Directives, Appointment of Healthcare Agent or Surrogate, POST Form, revised 1/8/2024, revealed, .Purpose .To provide guidance to support and facilitate a resident's right to .formulate an advance directive .Residents will be informed, and written information provide, during the admission process, regarding the right to accept or refuse medical or surgical treatment. The facility will honor the Advance Directive as the resident's wishes for future care and treatment .The facility recognizes the resident has the right to formulate an Advance Directive .The facility representative will discuss and provide written information explaining the Advance Directive Program, upon…

  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 · E2023-11-15 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to revise care plans for 10 of 17 (Resident #1, #2, #3, #5, #7, #8, #9, #10, #14 and #17) residents reviewed for advanced directives, behaviors, and wounds. The findings include: 1. Review of the facility policy titled, Comprehensive Careplan, with a revision date of 10/24/2022, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan shall describe, at a minimum .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Resident specific interventions that reflect the resident's needs and preferences . Review of the…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-11-15 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on facility orientation and competency assessment review, facility employee file review, medical record review, and interview, the facility failed to ensure the licensed nurses had the competencies and skill sets necessary to document assessments and administer intravenous medications for 1 of 3 Licensed Practical Nurses (LPN #2) for 1 of 1 sampled resident (Resident #1) receiving antibiotic therapy via peripherally inserted central catheter. The findings include: 1.Review of the Orientation and Competency Assessment Nursing-LPN revealed .PEER LEADER: As skills/competencies are reviewed with the employee or return demonstration is satisfactorily completed by the employee, place date and Peer Leader Initials in columns 4 or 5 to the appropriate skill/competency . 2. Review of the employee personnel file of Licensed Practical Nurse [LPN] #2 revealed the employee had not been evaluated to ensure the knowledge and skill sets were competent to document assessments and care for the facility's residents receiving intravenous therapy. 3. Review of the medical record of Resident #1,…

  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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

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

Follow the money — this home’s finances

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

About 79% 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 $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 21% 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