No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Avondale Health and Rehabilitation Center, LLC

2031 Avondale Street Po Box 446, Humboldt, TN 38343 · For profit - Limited Liability company · 89 certified beds · (731) 784-3655 Medicare & Medicaid certified

Call the home — (731) 784-3655 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jun 2026Resident-funds citation (F0565)1 actual-harm citation
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (56%) runs well above the national median (45%)
  • about 20% of its spending goes to commonly-owned related companies

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1804 E Main St · (731) 784-7833 · Call to confirm hours
Pharmacy
2110 N Central Ave · (731) 201-5010 · Call to confirm hours
Grocery
2419 N Central Ave · (731) 784-3022 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
2001 Highway 45 Byp · (731) 784-3981

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 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 increased7.5%14.0%15.4%better
Long-stay residents who lose too much weight2.6%6.1%5.4%better
Long-stay residents with a catheter left in their bladder0.9%0.7%0.9%typical
Long-stay residents with a urinary tract infection1.4%1.8%2.0%better
Long-stay residents with depressive symptoms31.5%13.8%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.1%3.4%3.3%worse
Long-stay residents whose ability to walk worsened15.4%17.2%16.1%typical
Long-stay residents on antianxiety or hypnotic medication41.6%31.7%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers5.2%5.0%4.7%typical
Long-stay residents with worsening bladder/bowel control26.4%20.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table23.1%16.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.7%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%79.8%79.4%better
Short-stay residents rehospitalized after admission28.3%22.6%22.6%worse
Short-stay residents with an outpatient ER visit11.7%11.2%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.061.671.67worse
Long-stay outpatient ER visits per 1,000 resident days1.581.561.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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

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

43.8% 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 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

43.8%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
51.3%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 51.3% 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 39 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 0.32 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF43.8%CMS range 32.0–53.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 6.1–12.310.7%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 discharge51.3%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 discharge56.4%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 discharge51.3%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 identified98.3%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 setting95.2%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.7%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 worsened1.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.4%CMS range 4.1–12.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.131.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.47
RN hours/ resident / day
1.18
LPN hours/ resident / day
1.66
Aide hours/ resident / day
3.31
Total nurse hours/ resident / day
0.33
RN hoursweekends
56.3%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 89 beds and averages 67.0 residents a day — about 75% occupied, or roughly 22 beds typically open. It usually has some room. 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 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.66 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.90 hrs/resident/day on weekends vs 3.48 on weekdays — 17% thinner on weekends. RN hours go from 0.52 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% 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

11
deficiencies at the latest standard inspection (2025-01-09)
6
at the previous standard inspection (2023-09-22)

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.

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.

19 citations, most serious first. The 11 most serious are shown; the remaining 8 are one tap away and print in full.

  • Actual harm · G2019-06-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    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 National Pressure Ulcer Advisory Panel (NPUAP) quick reference guide, policy review, medical record review, observation, and interview, the facility failed to identify a pressure ulcer and obtain a physician's order for the treatment of the pressure ulcer before it deteriorated to a Stage 3 pressure ulcer for 1 of 5 (Resident #1) sampled residents reviewed for pressure ulcers. The failure of the facility to perform a skin assessment, identify a pressure ulcer, and obtain a physician's order before the pressure ulcer progressed to a Stage 3 pressure ulcer resulted in actual Harm for Resident #1. The findings include: Review of the NPUAP quick reference guide, revised 4/13/16, defined a Stage 3 pressure ulcer as .Full thickness loss of skin .Slough and/or Eschar may be visible. The depth of tissue damage varies .Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed . The facility's Pressure Injury Prevention and Non-Pressure Ulcer Management policy revised 5/2019 documented, .This…

    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 · D2026-06-12 · 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 facility policy review, medical record review and interview, the facility failed to report an allegation of abuse for 1 of 3 (Resident #2) sampled residents reviewed for abuse. The findings include: 1. Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 12/2/2024, revealed .It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.Abuse means the willful infliction of.intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse.Alleged violation is a situation or occurrence that is observed or reported by staff or resident.but has not yet been investigated.Mental Abuse includes but is not limited to humiliation, harassment, threats of punishment.The facility will have written procedures that include.Reporting of all alleged violations to the Administrator, state agency,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-09 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, record review, and interview, the facility failed to post the total number of staff, and actual hours worked by the licensed and unlicensed staff responsible for resident care on the facility's Daily Nurse Staffing form for 31 of 31 sampled days. The findings include: 1. Review of the facility policy titled, Nurse Staffing Posting Information, dated 12/1/2024, revealed .It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time .will contain the following information .Facility name .total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift .Registered Nurses(RNs) .Licensed Practical Nurses(LPNs) .Certified Nurse Aides(CNAs) . 2. Review of the facility's Daily Nurse Staffing forms dated 12/2/2024 thru 1/2/2025, revealed there were no total number of RN's, LPN's, and CNA's and no total of the actual hours worked by the RNs, LPNs, and CNAs. During an interview 1/9/2025 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-09 · tag F0801 — pattern
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on job description review, and interview, the facility failed to ensure a full-time or part-time Registered Dietitian (RD), or a qualified Dietary Manager (DM) was employed to provide oversight of the kitchen, kitchen staff competencies, residents' prescribed diets, and meals served in a timely manner. This had the potential to affect 55 of 55 residents who received a tray from the kitchen. The findings include: 1. Review of a Registered Dietitian job description revealed .Major Duties and Responsibilities .Provides registered dietitian services in one or more sites according to policies and procedures, and federal and state requirements. Plans, organizes, develops, and directs the nutritional care of the resident in accordance with current federal, state, and local standards, guidelines and regulations. Assesses/Monitors the residents' nutritional status and provides recommendations to clinical/medical staff. Develop and updates nutritional care plans as needed. Observes resident meal service to ensure diets are correct and modifications are followed. Educates residents,…

    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 · E2025-01-09 · tag F0802 — failed to prepare enough nourishing food — pattern
    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 policy review, document review, observation, and interview, the facility failed to provide sufficient staff with competencies and skill sets to carry out the functions of the food and nutrition services for 4 of 4 staff members (Dietary [NAME] C, D, F, and Dietary Supervisor) working in the kitchen. The facility had a census of 55, with 55 of those residents receiving a meal tray from the kitchen. The findings include: 1. Review of the facility policy titled, Food Safety Requirements, dated 12/1/2024, revealed .Food safety practices shall be followed throughout the facility's entire food handling process .This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include .Distribution and service of food to the resident, including transportation, set up, and assistance .Employee hygienic practices .Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely storage .Labeling, dating, and monitoring refrigerated food,…

    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 · E2025-01-09 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, observation, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions when for 2 of 4 (Dietary [NAME] C and Dietary [NAME] D) dietary staff failed to perform hand hygiene, and when 1 of 4 (Dietary [NAME] D) failed to test the sanitation of the 3 compartment sink prior to use, when unlabeled, undated, and expired foods were stored in the kitchen. The facility had a census of 55 with 55 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility policy titled, Food Safety Requirements, dated 12/1/2024, revealed .Food safety practices shall be followed throughout the facility's entire food handling process .Employee hygienic practices .Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely storage .Labeling, dating, and monitoring refrigerated food, including but not limited to left overs, so its used by its use by date, or frozen (where applicable) and discarded .Staff shall…

    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 · E2025-01-09 · 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 infection control practices were followed during medication administration when 1 of 4 (Licensed Practical Nurse (LPN G)) staff were observed during medication administration, when 1 of 1 (LPN A) LPN failed to follow Enhanced Barrier Precautions when administering PEG (percutaneous endoscopic gastrostomy) tube medications, during dining when the facility failed to follow transmission based precautions for 1 of 1 (Resident #159) reviewed for isolation, and when a random observation revealed LPN H failed to perform proper hand hygiene and failed to clean reusable medical equipment. The findings include: 1. Review of the facility's policy titled, Isolation Precautions, revealed .The dietary department should be notified by nursing or other designated person that the precautions are needed, the notification should include the residents name, room number and any other pertinent information . 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to revise a person-centered care plan for 1 of 15 (Resident #25) residents reviewed for weight gain and weight loss. The findings include: 1. Review of the facility's policy titled, Comprehensive Care Plan, dated 12/1/2024, 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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will describe .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 2. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Coronary Artery Disease, Failure to Thrive, Diabetes,…

    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 · D2025-01-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to follow the physician orders for 2 of 15 (Resident #31 and Resident #159) sampled residents reviewed. The findings include: 1. Review of the facility policy titled, Consulting Physician/Practitioner Orders, dated 12/1/2024, revealed .Consulting physician/practitioner orders are those orders provided to the facility by a physician/practitioner other than the resident's attending physician or physician/practitioner who is acting on behalf of the attending physician. A consulting physician/practitioner may include, but not limited to a resident's .Nurse practitioner .For consulting physician/practitioner orders received via telephone, the nurse will .Document the order on the physician order form, notating the time, date, name, title of the person providing the order, and signature and title of the person receiving the order. Call the attending physician to verify the order. Document the verification of the order by entering the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview, the facility failed to ensure a resident's dignity for 1 of 3 (Resident #13) residents reviewed for the use of an indwelling urinary catheter. The findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis (MS), Depression, Anxiety, Urinary Tract Infection (UTI), and Disorder of Bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, that indicated the resident was cognitively intact, dependent on staff for activities of daily living, incontinent of bowel and bladder, and diagnoses of UTI, MS, and the use of an antibiotic. Review of the Care plan dated 12/20/2024, revealed .has an Indwelling Catheter .Bladder disorder and MS . Review of a Physician Order dated 12/29/2024, revealed .Privacy bag in place for dignity every shift . Observations in Resident #13's room on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 care to ensure that acceptable parameters of nutritional status were maintained for 1 of 15 (Resident #25) reviewed for weight gain and loss. The findings include: 1. Review of the facility policy titled, Nutritional Management, dated 12/1/2024, revealed .Weight related interventions .Monitoring/Revision .The care plan will be updated as needed, such as when a resident's condition changes, goals are met or the resident changes his or her goals, interventions are determined to be ineffective, or as new causes of nutrition-related problems are identified .The physician will be notified of significant changes in weight, intake or nutritional status . Review of the facility policy titled, Weight Monitoring, dated 12/1/2024, revealed .Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight range and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 8 citations
  • Potential for harm · D2025-01-09 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    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, record review, and interview, the facility failed to reassess the effectiveness of pain medication for 1 of 15 (Resident #41) sampled residents reviewed for pain management. The findings include: 1. Review of the facility policy titled, Pain Management, dated 12/1/2024, revealed .The facility must ensure that pain management is provided to residents who require such services .The facility .will develop, implement, monitor, and revise interventions to prevent or manage each individual resident's pain .monitoring the effectiveness of the medication . 2. Review of the medical record revealed Resident #41 admitted to the facility on [DATE], with diagnoses including Hidradenitis Suppurativa (a chronic skin condition that causes painful lumps, boils and tunnels under the skin), Diabetes, End Stage Renal Failure, Pain, and Cellulitis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-09 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored in 1 of 4 (Medication Room) medication storage areas, when internal medications were stored with external medications and when nasal spray was stored with ear drops. The findings include: 1. Review of the facility policy titled, Medication Storage, dated 12/1/2024, revealed It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medications rooms .to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .External Products .drugs for external use are stored separately from internal and injectable medications .Internal Products .Medications to be administered by mouth are stored separately from other formulations .eye drops, ear drops, injectables . 2. Observation in the Medication Room on 1/7/2025 at 2:20 PM, revealed the following: a. Four 1.3 oz (ounce) plastic tubes of glucose gel (an oral medication given to raise blood glucose levels) stored in a 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-22 · 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

    Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 3 of 11 staff members (Certified Nursing Assistant (CNA) #1, CNA #2, and CNA #3) observed during dining failed to knock and/or announce herself before entering a room, failed to use courtesy titles, and referred to residents as feeders. The findings include: The facility's Promoting/Maintaining Resident Dignity Policy, dated 10/24/2022, revealed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .Speak respectfully to residents . Observation in resident's room on 9/18/2023 beginning at 12:10 PM, revealed CNA #1 placed the meal tray on the over the bed table and stated, I'll get to it baby…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-22 · tag F0565 — failed to support the resident council — isolated
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, observation, and interview, the facility failed to provide privacy during 1 of 1 meeting with active Resident Council members. The findings include: The facility's Resident Council Meeting Policy, revised 5/15/2023 revealed, .The facility shall provide the Resident Council with a private space to meet .Staff members may attend the council meetings only at the request of the group . Observation on 9/20/2023 at approximately 1:37 PM, revealed, the Resident Council meeting was called to order by the Activities Director, with Resident #1, #11, #19, #25, #39, #40, and #41 in attendance. The Activities Director exited the meeting and entered her office approximately10 feet from the meeting space, sat at her desk with the door to her office remaining open during the Resident Council meeting. Observation during the Resident Council Meeting held in the facility's Dining Room on 9/20/23 at 1:37 PM, revealed 2 staff members sitting at tables at the back of the dining room, Certified Nursing Assistant (CNA) #4 was sitting by the window near the piano eating her lunch and…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure activities of daily living assistance was provided related to good grooming, personal hygiene, and nail care for 3 of 4 (Resident #3, #6, and #42) sampled residents reviewed for activities of daily living. The findings include: The facility's Activities of Daily Living (ADL), policy dated 3/9/2023, revealed .Care and services shall be provided for the following activities of daily living .Bathing, dressing, grooming and oral care .A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . The facility's Dietary-Dining Services, policy dated 3/8/2023, revealed, .The nursing staff shall be responsible to properly prepare the resident for the dining service .Appropriate hygiene provided prior to meals being served .dignity shall be maintained .Residents shall be assisted with hand hygiene before meals…

    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 · D2023-09-22 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 medications were available for administration for 1 of 4 (Resident #22) sampled residents observed during medication administration. The findings include: Review of the facility's policy titled, Medication and Biological Storage, Night/ Emergency Box and Backup Pharmacy, revised 8/2021, revealed .To outline process for medication and biological storage and back-up medications and pharmacy .The nurse shall check the hospital's back-up box/I-Stat .If medication is not available in the back-up box, the medication shall be ordered from the back-up pharmacy . Review of the facility's policy titled, Medication Administration, revised 8/4/2023, revealed .Medications shall be administered by licensed medical or nursing personnel acting within the scope of their practice and per the Physician's Signed Order. While administering medications the nurse shall observe the 8 Rights of Medication Administration .Right Time…

    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 before2023-09-22 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 2 of 2 staff members (Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1) left the medications unattended and unsecured, and when external and internal (oral) medications were stored together in the medication cart. The findings include: Review of the facility's policy titled, Medication and Biological Storage, Night/Emergency Box and Backup Pharmacy, revised 8/2021, revealed .All medications are stored in designated areas which are sufficient to ensure proper sanitation .and security .drugs for external use are stored separately from internal and injectable medications . Observation during medication administration on 9/20/23 at 9:43 AM, revealed RN #1 gathered medications for administration to Resident #22, placed the medications in a medication cup, knocked and entered Resident #22's room, leaving a bottle of lactobacilli (a medication used to treat bacteria in the stomach) sitting on top of the medication cart, unattended and unsecured.…

    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 · D2023-09-22 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, observation, and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for 4 of 39 (Resident #3, #6, #12, ,and #42) resident rooms. The findings included: The facility's Housekeeping-Cleaning and Disinfecting, policy revised 5/15/2023, revealed, .It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible .Routine cleaning of environmental surfaces and non-critical resident care items shall be performed .to keep surfaces clean and dust free .Specific areas include .Resident rooms .floors shall be cleaned last .In some facilities the Nursing staff designated for caring for residents may need to complete the housekeeping duties . Observations in Resident #42's room on 9/18/23 at 9:55 AM, and 10:46 AM, revealed a light brown sticky substance on the floor on the right side of the residents bed extending to underneath the bed and to the heating and air conditioning…

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

    Environmental Deficiencies · Deficient, Provider has date of correction

“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

No federal fines in the current CMS record.

Part of a chain

This home belongs to CHAMPION CARE — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.2-0.2 vs chain
Health inspection 2 of 52.1-0.1 vs chain
Staffing 2 of 52.3-0.3 vs chain
Quality measures 3 of 53.0≈ chain avg
The other 21 homes this chain runs (chain average 2.2★, per CMS)
1 of 5Burlington Health and Rehabilitation CenterBurlington, WI 1 of 5Lyonsview Health And Rehabilitation CenterKnoxville, TN 1 of 5Madison Health and Rehabilitation CenterMadison, WI 1 of 5Manahawkin Health And Rehabilitation CenterManahawkin, NJ 1 of 5Suring Health and Rehab CenterSuring, WI 1 of 5Waters Edge Health and Rehabilitation CenterKenosha, WI 2 of 5Beloit Health And Rehabilitation CenterBeloit, WI 2 of 5Eastview Health and Rehabilitation CenterAntigo, WI 2 of 5Highlands Health And Rehabilitation CenterMemphis, TN 2 of 5Muskego Health and Rehabilitation CenterMuskego, WI 2 of 5North Ridge Health and Rehabilitation CenterManitowoc, WI 2 of 5Oconto Health and Rehab CenterOconto, WI 2 of 5Riverside Health And Rehabilitation Center LLCTrenton, NJ 2 of 5Sheridan Health and Rehabilitation CenterKenosha, WI 3 of 5Monroe Health And Rehabilitation CenterMadisonville, TN 3 of 5Patriot Health and Rehabilitation CenterParis, TN 4 of 5Dyersburg Health And Rehabilitation CenterDyersburg, TN 4 of 5Nu Roc Health and Rehabilitation CTRLaona, WI 4 of 5Okeena Health And Rehabilitation Center LLCDyersburg, TN 4 of 5St Ann Health and Rehabilitation CenterMilwaukee, WINot rated (Special Focus)Medical Suites at Oak Creek (The)Oak Creek, WI

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
TN3 OPCO HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2025
FINK, EPHRAIMIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST6%since 01/01/2025
ARINZE, FESTUSIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
MOORE, CHARLESIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
RUVEL, MENACHEMIndividualADP OF THE SNFsince 01/10/2025
WEINBERG, YISROELIndividualADP OF THE SNFsince 01/10/2025

CMS files one row per role, so the 8 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$5.7M
Net patient revenuemost recent cost report
-12.9%
Operating marginrevenue minus expenses
$1.3M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 13%Other / private 23%

This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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

$346per resident / day
operating cost
$10,506per month
≈ monthly operating cost
$306per 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 445454. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

What to do next