Maplewood Health Care Center

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.

41.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 69 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 37.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 64 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 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 160 beds and averages 112.5 residents a day — about 70% occupied, or roughly 48 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 3.85 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.30 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 3.41 hrs/resident/day on weekends vs 4.03 on weekdays — 15% thinner on weekends. RN hours go from 0.51 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 67% is well above 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.

26 citations, most serious first. The 15 most serious are shown; the remaining 11 are one tap away and print in full.

• Immediate jeopardy · J2025-03-03 · 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, facility daily staffing review, medical record review, hospital record review, and interview, the facility failed to ensure residents were free of neglect as evidenced by the facility's failure to provide sufficient licensed nursing staff to perform assessments and administer morning medications as ordered for 6 of 6 (Resident #1,#2, #3, #4, #5, and #6) sampled residents reviewed. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1 experienced a change of condition, and a nurse was not available on the 100 Hall to assess Resident #1. Resident #1's spouse called 911. Resident #1 was evaluated in the Emergency Department (ED) and admitted to the hospital. Resident #2 did not receive the morning blood glucose check, scheduled Insulin or Metformin, as ordered by the physician on 2/23/2025, and at 7:46 PM, Resident #2's blood glucose level reached 402 milligrams per deciliter (mg/dl). Immediate Jeopardy (IJ) is a situation in which a provider's noncompliance with one or…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-01-15 · 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 policy review, medical record review, observation, and interview, the facility failed to provide care and services to prevent the development of a pressure ulcer/injury and failed to provide treatments for 2 of 4 (Residents #72, and #85) sampled residents reviewed for pressure ulcers/injuries. Resident #72, who was at risk of developing pressure ulcers/injuries due to contractures [a permanent tightening of muscles, tendons, ligaments, skin, or other tissues that limits movement of a joint or body part] of the extremities and was dependent on staff for preventative interventions, developed a pressure ulcer/injury to the palm of her left hand from having long fingernails embedded into the skin, resulting in actual Harm to Resident #72. The findings include: 1. Review of the facility's undated policy titled, Activities of Daily Living (ADLs), revealed A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good .grooming .personal .hygiene .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
• Actual harm · Gcited before2025-01-15 · 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, facility investigation review, and interview, the facility failed to implement fall interventions for 1 of 4 (Resident #56) sampled residents reviewed for falls. The facility failed to follow the fall prevention intervention of 2 person bed mobility assistance, when on 11/17/2024, Resident #56 fell out of the bed and sustained a fractured hip, resulting in Actual HARM to Resident #56. The findings include: 1. Review of the facility's undated policy titled, Fall Prevention Program, revealed .Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .The nurse will indicate the resident's fall risk . and initiate interventions on the resident's baseline care plan .with the resident's level of risk . Review of the facility's undated policy titled, Comprehensive Care Plan Policy, revealed .Qualified staff responsible for carrying out interventions specified in 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
• Actual harm · Gcited before2022-08-19 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, policy review, medical record review, observation, and interview, the facility failed to ensure the Responsible Party was notified of a newly identified pressure ulcer, failed to ensure the Wound Care Nurse was notified of skin condition changes, and failed to ensure the Physician was notified and orders were obtained for a newly identified pressure ulcer for 1 of 5 sampled residents (Resident #42) reviewed with in-house acquired pressure ulcers. The facility's failure to notify the Wound Care Nurse of skin condition changes/redness and to notify the Physician and obtain orders for a newly identified pressure ulcer resulted in actual Harm when skin condition changes deteriorated and progressed to an Unstageable pressure ulcer. The findings include: Review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide,…

  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
• Actual harm · Gcited before2022-08-19 · 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 review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, policy review, medical record review, observation, and interview, the facility failed to ensure changes in a resident's skin condition were identified, assessed, reported, a physician's order for treatment was obtained and treatments were provided before the skin condition changes deteriorated to an Unstageable Pressure Ulcer and failed to ensure a pressure ulcer was accurately assessed and identified before it became an unstageable pressure ulcer for 2 of 5 sampled residents (Resident #42 and #99) reviewed with in-house acquired pressure ulcers. The facility's failure to identify, assess, report, and provide treatment before newly identified skin changes and pressure ulcers deteriorated and progressed to Unstageable pressure ulcers resulted in actual Harm for Resident #42 and Resident #99. The findings include: Review of the National Pressure Ulcer Advisory Panel (NPUAP)…

  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 before2026-03-25 · 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 maintain and ensure the prevention and spread of infection when staff failed to use Personal Protective Equipment (PPE) during dining and medication administration for 3 of 8 (Resident #7, #47, and #114) sampled residents reviewed. The findings include: 1. Review of the undated facility policy titled, Transmission-Based (Isolation) Precautions [TBP], revealed .Contact precautions.refer to measures.to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment.Droplet precautions.actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions.will don [put on] appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions.Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-01-15 · 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, kitchen sanitation logs, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions. The kitchen floor was dirty, the cook ware had sticky black carbon build-up, the convection oven had dried food particles inside with thick black sticky substance buildup. The meal and miscellaneous carts were dirty with dry food particles inside the carts. The facility failed to complete the food temperature log, freezer log, and cooler log. The facility failed to check the dish washer temperatures and sanitizing solution level three times a day. The facility had a census of 103 with 101 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility undated policy titled, Sanitation Inspection, revealed .It is the policy of this facility to conduct inspections to ensure food service areas are clean, sanitary and in compliance with .state and federal regulations. All food service areas shall be kept clean, sanitary, free from litter .Daily: Food service 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 · Dcited before2025-01-15 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on policy review, observation, and interview the facility failed to provide a private space that prevented interference for the resident group meeting for 1 of 1 (Resident Council) sampled group reviewed. The findings include: 1. Review of the facility's policy titled, Resident Council Procedural Guide, dated 11/28/2017, revealed .facility supports the rights of residents to organize and participate in resident groups .The resident has a right to organize and participate in resident groups in the facility .The facility must provide a resident .private space .they must be provided privacy for meetings . 2. Observation in the Dining Room on 1/9/2025 at 10:20 AM, during the Resident Council Meeting, revealed the Maintenance Director came into the Dining Room, walked in front of the residents in the group meeting, and exited down the facility hallway. Observation in the Dining Room on 1/9/2025 at 10:28 AM, during the Resident Council Meeting, revealed the Maintenance Assistant came into the Dining Room, walked in front of the residents in the group meeting, and exited down the…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-15 · 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 a private space that prevented interference for the resident group meeting for 1 of 1 (Resident Council) sampled group reviewed. The findings include: 1. Review of the facility's policy titled, Resident Council Procedural Guide, dated 11/28/2017, revealed .facility supports the rights of residents to organize and participate in resident groups .The resident has a right to organize and participate in resident groups in the facility .The facility must provide a resident .private space .they must be provided privacy for meetings . 2. Observation in the Dining Room on 1/9/2025 at 10:20 AM, during the Resident Council Meeting, revealed the Maintenance Director came into the Dining Room, walked in front of the residents in the group meeting, and exited down the facility hallway. Observation in the Dining Room on 1/9/2025 at 10:28 AM, during the Resident Council Meeting, revealed the Maintenance Assistant came into the Dining Room, walked in front of the residents in the group meeting, and exited down the…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-15 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 and interview, the facility failed to notify the resident's legal representative of a transfer of the resident from the facility for 1 of 1 (Resident #81) sampled resident reviewed for notification of change. The findings include: 1. Review of the undated facility policy titled, Notification of Changes, revealed .The facility must inform .or notify the resident's family member or legal representative when there is a change requiring such notification .Circumstances requiring notification include .A transfer or discharge of the resident from the facility . Review of the undated facility policy titled, Transfer and Discharge (including AMA), revealed .Emergency Transfers/ Discharges- initiated by the facility for medical reasons .Notify resident and/or resident representatives . 2. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Dementia, Alzheimer's Disease, and Gastro-Esophageal Reflux.…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-15 · 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

  Based on policy review, observation, and interview, the facility failed to provide effective housekeeping to maintain a sanitary environment for 4 of 86 resident rooms (Residents #3, #28, #34, #61, #82, #84, and #94) The findings include: 1. Review of the undated facility policy Resident Rights, revealed .The resident has a right to a safe, clean, comfortable and homelike environment . Review of the facility's CLEANING SCHEDULE, dated 10/11/2023, revealed .Monday .Wednesday .Friday .Sunday .Clean commode top to base of commode .Wednesday .Friday .clean .IV poles .Monday .Clean walls, light, everything on the wall, wash window and window seal .Daily dust mop and mop room . Review of the facility's Deep Cleaning List, revealed .Dust and polish all furniture .Dry mop and wet mop entire floor-move all furniture .clean windows, screens, ledges, blinds .Dust high areas .curtain -window and cubicle .Clean Feeding Tube Poles .Clean and disinfect toilet bowl . 2. Multiple observations in Resident #3's room on 1/6/2025 at 9:50 AM, 1/7/2024 at 8:18 AM, and on 1/8/2025 at 8:27 AM, revealed…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-15 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to report an allegation of staff to resident abuse for (Resident #76 and #307) and an injury of unknown origin (Resident #81) for 3 of 10 sampled residents reviewed for Abuse. The finding include: 1. Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation revealed, .Abuse .includes verbal abuse, sexual abuse, physical abuse, and mental abuse .verbal abuse .includes disparaging and derogatory terms to residents .physical .hitting, slapping .includes controlling behavior through corporal punishment .designate an Abuse Coordinator in the facility who is responsible for reporting allegations or suspected abuse . to the state survey agency and other officials in accordance with state law .Possible indicators of abuse include .Resident, staff, or family report of abuse .physical marks such as bruises .physical injury of a resident, of a unknown source .Reporting of all alleged violations to the Administrator,…

  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 · D2025-01-15 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to thoroughly investigate alleged allegations of abuse that included an injury of unknown origin (Resident #81) and staff to resident abuse (Resident #307) for 2 of 11 sampled residents reviewed for abuse. The findings include: 1. Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed . An immediate investigation is warranted .B. Written procedures for investigation include .Identifying staff responsible for the investigation . Investigating different types of alleged violations .Identifying and interviewing all involved persons, including the alleged victim .others who might have knowledge of the allegations .Focusing the investigation on determining if abuse . and/or mistreatment has occurred, the extent, and cause .Providing complete and thorough documentation of the investigation . Review of the facility's undated policy titled, .Incidents and Accidents, revealed It is the policy of 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-15 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to develop a care plan for 1 of 32 (Resident #72) residents reviewed for care plans. The findings include: 1. Review of the facility's undated policy titled, Pressure Ulcer Prevention and Management, revealed This facility is committed to the prevention of avoidable pressure injuries .Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse timely .Interventions will be based on specific factors .skin assessment .moisture management, impaired mobility .Interventions will be documented in the care plan and communicated to all relevant staff . 2. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Epilepsy, Left Knee Contracture, and Right Knee Contracture. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #72…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-15 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to conduct a quarterly care plan conference meetings with resident/family representative for 1 of 32 (Resident #68) sampled residents reviewed for care plan meetings. The findings include: 1. Review of the undated facility policy titled, Comprehensive Care Plans revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .The care planning process will include an assessment of the resident's personal and cultural preferences in developing goals of care .The comprehensive care plan will be prepared by an interdisciplinary team, that includes .Family members, surrogate, or others desired by the resident .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set [MDS] assessment . 2. Review of the medical record revealed Resident #68 was admitted to the facility on [DATE], with…

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

  Resident Assessment and Care Planning 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

$93,678 in federal fines across 1 penalty.

• $93,678 — penalty dated 2025-01-15

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 AHAVA HEALTHCARE — 16 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 7 rows in the source record cover these 4 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.

This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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