Cypress Grove Post Acute

Location & what’s nearby

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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.

38.5% 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 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 59.3% 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 27 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 0.42 therapist hours per resident per day in 2026Q1 — more than 71% 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 170 beds and averages 105.6 residents a day — about 62% occupied, or roughly 64 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 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.14 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 3.44 hrs/resident/day on weekends vs 3.84 on weekdays — 11% thinner on weekends. RN hours go from 0.53 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.

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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

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.

24 citations, most serious first. The 13 most serious are shown; the remaining 11 are one tap away and print in full.

• Immediate jeopardy · J2022-07-14 · 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 provide a safe environment and ensure supervision to prevent neglect for 1 of 3 sampled residents (Resident #36) reviewed for elopement risk. The facility's failure to provide care and services necessary to prevent neglect resulted in Immediate Jeopardy when Resident #36, a vulnerable resident with severe cognitive impairment was found 0.9 miles from the facility on a warm summer day. The facility was unaware of the resident's location for approximately 30-45 minutes. Resident #36 was located on the corner of a busy street in an [NAME] area by a facility staff member driving on her lunch break. Immediate Jeopardy (IJ) 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 and the Administrative staff were notified of the Immediate Jeopardy on 7/14/2022 at 9:43…

  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 · Past Non-Compliance
• Immediate jeopardy · Jcited before2022-07-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, weather website review, medical record review, observation, and interview, the facility failed to ensure a safe, secure environment for 1 of 3 sampled residents (Resident #36) reviewed for elopement/wandering. The facility's failure to ensure a safe, secure environment resulted in Immediate Jeopardy when Resident #36, a vulnerable cognitively impaired resident, exited the facility unsupervised through an unlocked door. Resident #36 was found by a facility staff member driving on her lunch break approximately 0.9 miles from the facility, approximately 30-45 minutes later. Immediate Jeopardy (IJ) 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 and impairment or death to a resident. The Administrator and the Administrative staff were notified of the Immediate Jeopardy (IJ) on 7/14/2022 at 9:43 PM, in the Administrator's office. The facility was cited Immediate Jeopardy at F-689. 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 · Past Non-Compliance
• Actual harm · G2024-09-25 · 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 the National Pressure Injury Advisory Panel 2019 Guidelines, policy review, medical record review, observation, and interview, the facility failed to provide care and services to appropriately identify pressure ulcers/pressure injuries (PU/PIs), to provide services to promote healing, and to promptly notify the physician or practitioner for changes in the right foot PU/PI wound status to reduce the risk for infection for 1 of 4 (Resident #9) sampled residents reviewed for PU/PIs. The facility's failure to timely implement wound care and promptly notify the physician or practitioner of Resident #9's deteriorating right foot PU/PI wound that developed drainage and had an odor, resulted in Actual Harm when Resident #9 was sent to the Emergency Room, admitted to the hospital with the diagnosis of Osteomyelitis [a serious infection of the bone], and underwent a 5th metatarsal [long bone in the foot] amputation [removal of the area, usually by surgical procedure]. The findings include: 1. 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure the environment was free of accident hazards when unsecured sharps were observed in 1 of 10 (Resident #18) resident bathrooms on the secured unit for 1 of 14 (Resident #18) residents observed for accident hazards. There were 10 Wandering residents on the secured unit. The findings include: 1. Review of the facility policy titled, Sharps Disposal, dated January 2012, revealed This facility shall discard contaminated sharps into designated containers .discard them immediately .into designated containers .containers that are .closable .puncture resistant . 2. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, Heart Failure, and Depression. Review of the Interdisciplinary Team (IDT) Care Conference documentation dated 4/7/2025, revealed .Resident OOB [Out of Bed] on wheelchair, propels self, eats meals in room, feeds self…

  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 before2025-06-18 · 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, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 2 of 4 (Licensed Practical Nurse (LPN) A and Registered Nurse (RN) E medications were observed unsecured and unattended in 2 of 7 (Memory Care Medication Cart and 300 Hall Medication Cart) medication storage areas. The findings include: 1. Review of the facility policy titled, Medication Labeling and Storage, dated February 2023, revealed .Medication carts and storage rooms containing medications and biologicals are locked when not in use .trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others . 2. Observation on 6/17/2025 at 11:02 AM, revealed Licensed Practical Nurse (LPN) A entered Resident #47's room, failed to lock the medication cart, and left the Memory Care Medication Cart unattended. During an interview on 6/17/2025 at 11:15 AM, LPN A confirmed the Memory Care medication cart should not have been left unlocked and unattended. During an observation 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-18 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure safe infection control practices to help prevent the spread of infectious diseases for 2 of 6 (Resident #4 and #44) residents observed during medication administration when 2 of 4 nurses (Registered Nurse (RN) E and Licensed Practical Nurse (LPN) D) failed to disinfect a stethoscope and use a clean syringe after the syringe was contaminated. The findings include: 1. Review of the facility policy titled, Infection Prevention and Control Program, dated October 2018, revealed .educating staff and ensuring that they adhere to proper techniques and procedures . Review of the facility's policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, dated 2022, revealed Reusable items are cleaned and disinfected between residents .items are cleaned/disinfected between uses . 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Chronic…

  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 before2024-09-25 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, and interview, the facility failed to provide a clean and sanitary environment for 3 of 4 (100-Hall, 200-Hall and 300-Hall) hallways observed. The findings include: 1. Review of the facility's policy, titled Housekeeping-Cleaning and Disinfecting, revised 4/22/2024, 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 .Report to the Administrator and Maintenance areas with mold, cracked tile/grout, or any damaged items in need of repair . 2. Observations on the 100 Hall on 9/18/2024 at 9:55 AM, and 3:55 PM, by the nurse's station revealed a ceiling tile that appeared to be wet and had brown areas on the ceiling tile. Observations on the 200 Hall on 9/18/2024 at 10:00 AM, and 4:00 PM, at the end of the hallway by room [ROOM NUMBER] revealed 4 ceiling tiles, that appeared to have black areas 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2022-07-14 · 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 spread of infection were followed when 1 of 1 nurses (Licensed Practical Nurse (LPN) #7) failed to perform proper hand hygiene during wound care for 2 of 2 sampled residents (Resident #32 and #43) reviewed during wound care. The findings include: Review of the facility's policy titled, Hand Hygiene, dated 3/2022, revealed .Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .The use of gloves does not replace hand hygiene .Perform hand hygiene after removing gloves .Before and after handling clean or soiled dressings .Before performing resident care procedures . Review of the facility's undated policy titled, .Dressing Change Competency, revealed .Remove old dressing .Doff [remove] gloves, perform hand hygiene and [NAME] [putting on] new gloves .Once wound cleaned .Doff…

  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 · D2022-07-14 · tag F0553 — failed to let residents help plan their care — isolated
  Allow resident to participate in the development and implementation of his or her person-centered plan of care.
  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 2 of 18 sampled residents (Resident #12 and #32) or their families were invited to participate in planning their care. The findings include: Review of the facility's policy titled, Comprehensive Careplan, dated 3/25/2022, revealed .The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to .The attending physician .registered nurse .nurse aide with responsibility for the resident .food and nutrition services staff .The resident and the resident's representative .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment . Review of the medical record, revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of Paraplegia, Anemia, Hypertension, and Anxiety. Review of Resident 12's last Care Plan meeting held on 1/19/2022 had no documentation that…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2022-07-14 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to provide reasonable accommodations to meet the residents' needs for the use of a call light for 2 of 25 sampled residents (Resident #34 and #38) reviewed. The findings include: Review of the facility's policy titled, .Call Lights: Accessibility and Response, revealed .is to ensure resident call light accessibility and response .With each interaction in the Resident's room or bathroom, staff will ensure the call light is within reach of Resident and secured as needed . Review of the medical record, revealed Resident #34 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Hemiplegia, Chronic Obstructive Pulmonary Disease, and Anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderately impaired cognition. Observations in the resident's room on 7/11/2022 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2022-07-14 · 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 review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 dated October 2019, medical record review, and interview, the facility failed to ensure residents were accurately assessed for nutritional status and falls for 2 of 18 sampled residents (Resident #38 and #55) reviewed. The findings include: Review of the CMS LTC Facility RAI 3.0 User's Manual Version 1.17.1, dated October 2019, pages G-4 and K-4, revealed .In order to be able to promote the highest level of functioning among residents, clinical staff must first identify what the resident actually does for himself or herself, noting when assistance is received and clarifying the type .and level of assistance .provided by all disciplines . Review of the medical record, revealed Resident #38 was admitted to the facility on [DATE] with diagnoses of Encephalopathy, Hypertension, Diabetes, Congestive Heart Failure, and Morbid Obesity. Review of the quarterly Minimum Data Set…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2022-07-14 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to develop and implement a comprehensive Care Plan for antianxiety and anticoagulant medication and falls for 2 of 18 sampled residents (Resident #63 and #78) reviewed. The findings include: The facility policy titled, Comprehensive Careplan, dated 3/25/2022, revealed .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . Review of the medical record, revealed Resident #63 was admitted to the facility on [DATE] with diagnoses of Hypertension, Vascular Dementia, Anemia, Anxiety, and Depression. Review of the Care Plan dated 6/23/2022, revealed Resident #63 was at risk for falls with interventions to have a touch pad…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2022-07-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to follow Physician Orders for treatment of a Urinary Tract Infection for 1 of 2 sampled residents (Resident #8) reviewed with Urinary Tract Infections. The findings include: Review of the facility's policy titled, Medication Availability-Borrowing, dated 2/2022, revealed .If the resident's medication is not available, access the .machine or the back-up medication box to obtain the medication .Communicate the medication needs to the contracted pharmacy as soon as possible . Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Cystitis with Hematuria, Urinary Incontinence, and Dementia. Review of the Physician's Order dated 7/3/2022, revealed .Begin Date: 7/3/2022 .cephALEXin 500 mg [milligram] capsule [an antibiotic for infection] .Oral 2 Times Daily for 5 Days . Review of the Physician's Order dated 7/6/2022, revealed .Begin Date: 7/6/2022 .cephALEXin 500 mg .Oral 2 Times…

  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

“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

$17,355 in federal fines across 1 penalty.

• $17,355 — penalty dated 2024-09-25

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to LINKS HEALTHCARE GROUP — 32 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 →

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

CMS files one row per role, so the 12 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

About 83% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 18% 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