Beech Tree Health And Rehabilitation

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.

49.8% 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 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 66.7% 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 33 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 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% 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 110 beds and averages 99.5 residents a day — about 90% occupied, or roughly 10 beds typically open. It runs fairly full. 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 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.99 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 3.09 hrs/resident/day on weekends vs 3.37 on weekdays — 8% thinner on weekends. RN hours go from 0.52 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 45% 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 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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

23 citations, most serious first. The 18 most serious are shown; the remaining 5 are one tap away and print in full.

• Immediate jeopardy · Kcited before2024-04-11 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  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 Resident #24 was admitted to the facility on [DATE] with diagnoses including Lack of Coordination, Alzheimer's Disease, Dementia, Abnormalities of Gait and Mobility, and Muscle Weakness. Review of the comprehensive care plan for Resident #24 dated 8/22/2016, last revised on 4/23/2021, showed .I have impaired cognitive function r/t Dementia . Resident #24's care plan was not updated to reflect the resident to resident altercation on 2/9/2024. Review of the quarterly MDS assessment dated [DATE], showed Resident #24 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. Resident #24 exhibited no behavioral symptoms. Review of the SKIN- Head to Toe Weekly Skin Checks for Resident #24 dated 2/8/2024, showed the resident had no areas of skin impairment. Review of the Nursing Note for Resident #24 dated 2/9/2024 at 7:30 PM, showed .The nurse entered the room and witnessed an altercation between resident and the other resident [Resident #76] residing in the room. Assisted by the CNA the…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-04-11 · tag F0609 — failed to report abuse allegations — pattern
  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 Resident #91 was admitted to the facility on [DATE] with diagnoses including COVID-19 and Vascular Dementia with Agitation. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #91 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Review of the care plan dated 1/12/2024, showed Resident #91 had .impaired cognitive function/dementia .Administer medications as ordered. Observe/document for side effects and effectiveness . Review of the care plan dated 1/20/2024, showed Resident #91 had .Abusive verbal attacks on staff and others . There were no interventions for this focus on Resident #91's care plan. Review of the care plan dated 1/22/2024, showed Resident #91 had .Behavior Care Plan .Potential for impaired or inappropriate behaviors related to Dementia . Review of an Incident Report dated 3/30/2024 at 4:00 AM, showed LPN #2 filled out an incident report for an incident involving Resident #91 in the 300 Hall…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-04-11 · tag F0610 — failed to investigate and act on abuse reports — pattern
  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 Review of a hospital Discharge Documentation for Resident #40 dated 2/13/2024, showed Resident #40 previously resided in an assisted living facility where she was involved in an altercation with another resident and a staff member prior to this hospitalization. The assisted living facility would not accept the resident back due to her aggressive and irrational behaviors. Resident #40 was discharged from the hospital to the current facility where she resided. Resident #40 was admitted to the secure unit at the facility on 2/13/2024 with diagnoses including Dementia with Other Behavioral Disturbance, and Depression. Review of the Abuse Screening Indicator for Resident #40 dated 2/13/2024, showed she was evaluated in 5 categories to determine abuse risk factors. The category for History of abuse prior to admission documented, .Undetermined . The category for factors which increased the resident's vulnerability documented .Yes . and the category for history of dysfunctional behavior, (example), provoking,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-04-11 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for 9 residents (Residents #91, #40, #24, #73, #44, #46, #39, #20, and #78) of 37 residents reviewed for comprehensive care plans. The facility failed to address Resident #40's history of aggressive behaviors, with appropriate interventions. The facility failed to develop and implement a person-centered care plan related to Resident #91's wandering behaviors. Care plans were not developed to reflect the resident to resident altercations between Residents #40 and #91 on 3/30/2024, where Resident #91 sustained 3 scratches to the left cheek and 1 scratch above the eyebrow, Residents #24 and #73's altercation on 2/9/2024, where Resident #24 sustained an abrasion to the top of the head, redness to the face, and a bruise at the bridge of the nose and Resident #73 sustained a bruise to the bridge of the nose. Residents #44 and #46's care plan was not…

  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
• Immediate jeopardy · K2024-04-11 · tag F0835 — failed to run the facility competently — pattern
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, job description review, facility documentation review, medical record review, and interview, the facility's Administration failed to provide effective leadership and oversight to ensure effective systems were in place to ensure residents were free from abuse, identify serious outcomes related to abuse, investigate allegations of abuse, determine a root cause analysis (RCA) for abuse, develop and implement person centered care plans, report allegations of abuse to the local and state designated authorities, and discuss concerns related to abuse in Quality Assurance Performance Improvement (QAPI) and Governing Body (GB) meetings. The facility's Administration failed to ensure staff were educated and knowledgeable to recognize resident to resident altercations could lead to abuse regardless of cognitive status, injury of unknown origin as potential abuse, and to maintain an effective QAPI program placed 7 Residents (#39, #91, #40, #24, #73, #46, and #44), in an Immediate Jeopardy…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-04-11 · tag F0837 — pattern
  Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
  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, job description review, facility documentation review, medical record review, observation, and interview, the facility's Governing Body failed to provide effective leadership and oversight of the facility's Administration to ensure residents had the right to be free from abuse, failed to identify resident to resident altercations or injuries of unknown origin as the potential for abuse, failed to investigate resident to resident altercations and an injury of unknown origin, and failed to report resident to resident altercations and injury of unknown origin to the local and state designated authorities as required for 4 residents (Residents #39, #91,#24, and #46) of 37 residents reviewed for injury of unknown origin and abuse. The Governing Body's failure to provide adequate leadership and to oversee and maintain an effective QAPI program resulted in an Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-04-11 · tag F0867 — failed to act on quality-improvement findings — pattern
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, facility documentation review, medical record review, observation and interview, the facility's Quality Assurance Performance Improvement (QAPI) program failed to identify quality deficiencies, investigate, report, perform a root cause analysis to identify serious outcomes, develop and implement person centered interventions for 4 of 37 residents (Residents #39, #91, #24, and #46) related to an injury of unknown origin and abuse. The facility's failure to have an effective QAPI program resulted in an Immediate Jeopardy (IJ), (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 facility's failure to maintain an effective QAPI program and to identify serious outcomes and develop and implement person centered interventions related to abuse had the potential or likelihood to impact all 101 residents of the facility. The Administrator, Director…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-07-30 · 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 — the official record, unedited, may be distressing

  Deficiency Text Not Available

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has no plan of correction
• Potential for harm · F2024-04-11 · tag F0568 — widespread
  Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, facility documentation review, and interview, the facility failed to provide quarterly financial statements for 5 residents (Residents #8, #27, #28, #34, and #78) with personal fund accounts of 88 residents reviewed with personal fund accounts managed by the facility. The findings include: Review of the facility's undated policy titled, Resident Trust Funds, showed .The resident has a right to manage his or her financial affairs .The individual financial record must be available to the resident through quarterly statements and upon request . Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Paranoid Personality Disorder, Schizoaffective Disorder, and Major Depressive Disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #8 had moderate cognitive impairment. Review of a Resident Fund Statement for Resident #8 for the period of 12/30/2023 - 3/29/2024, showed an ending balance of $875.80.…

  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 · F2024-04-11 · tag F0732 — widespread
  Post nurse staffing information every day.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on facility policy review, observation, and interview, the facility failed to post accurate staffing information to reflect daily staffing levels on 7 days of 31 days reviewed for staffing. The findings include: Review of the facility's undated policy titled Staffing Posting Guidelines, showed .provide staffing information to the residents, visitors and staff .posting will include .current date .Total numbers of hours worked by the following categories of licensed and unlicensed nursing staff .RN's [Registered Nurses] .LPN's [Licensed Practical Nurses] .CNA's [Certified Nursing Assistants] .Administrator will designate a person to ensure updated information is entered into the staffing worksheet and posted in the lobby/entrance area .Administrator will designate a back-up person to ensure .documentation is posted .designated person(s) will ensure that the document includes accurate information . During an observation on 4/1/2024 at 8:35 AM, the daily nurse staffing information posted in the lobby was the staff scheduled for 3/28/2024 and had not been updated to reflect the…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-04-11 · tag F0641 — pattern
  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 Resident Assessment Instrument Manual 3.0 (RAI), medical record review, and interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments for 4 Residents (#39, #78, #20, and #46) of 31 residents reviewed for MDS assessments. The findings include: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 dated 10/2023, showed .assessments and documentation can be compared to baseline to identify changes in the resident's behavior .Review the medical record for the 7-day look-back period .Interview staff, across all shifts and disciplines, as well as others who had close interactions with the resident during the 7-day look-back period, including family or friends who visit frequently or have frequent contact with the resident .Observe the resident in a variety of situations during the 7-day look-back period .Active Diagnoses .to code diseases that have a direct relationship to the…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-04-11 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, and interviews, the facility failed to offer hand hygiene assistance to residents prior to meals for 5 residents (Residents #78, #203, #50, #54, and #79) observed in 1 of 2 dining areas and 2 of 3 resident units observed for meal tray distribution. The findings include: Review of the facility's policy titled, Hand Hygiene, dated 6/2023, showed .perform proper hand hygiene procedures to prevent the spread of infection .If residents need assistance with hand hygiene, staff should assist with washing hands .before meals . Resident #78 was admitted to the facility on [DATE] with diagnoses including Dementia, Mild Neurocognitive Disorder, and Major Depressive Disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #79 was cognitively intact. During an observation on 4/1/2024 at 12:42 PM, Licensed Practical Nurse (LPN) #9 delivered the lunch meal to Resident #78. The LPN assisted the resident with tray set up.…

  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 · D2024-04-11 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASRR) timely after a new mental health diagnosis for 2 residents (Residents #27 and #78) of 12 residents reviewed for PASRR. The findings include: Review of the facility's undated policy titled, PASARR Program, showed .This facility will provide guidance to the facility staff related to completion of PASARR screening .The goal is to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs .PASARR Level I - initial pre-screening that is completed prior to admission .Negative Level I Screen- permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later .Any resident who exhibits a newly evident or possible serious mental disorder .will be referred promptly to the state mental health or…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-11 · 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 facility policy review, medical record review, observation and interview, the facility failed to provide nail care during Activities of Daily Living (ADL) care for 1 resident (Resident #7) of 31 residents reviewed for ADL care. The findings include: Review of the facility's undated policy titled ADL CARE (Nails), showed .policy will provide the facility with guidance related to provision of care to resident's [residents'] nails for good grooming and health .nursing staff will provide routine cleaning and inspection of nails during ADL care on an ongoing basis . Resident #7 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, and Cerebral Infarction. Review of a care plan for Resident #7 dated 11/29/2022, showed .[resident] has an ADL self-care performance deficit r/t weakness, LBKA [left below the knee amputation] .with interventions of .resident requires extensive assistance .with personal hygiene . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE],…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-04-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to identify and complete a fall investigation for 1 Resident (#39) of 7 residents reviewed for falls. The findings include: Review of the facility's undated policy titled, Unusual Occurrences, showed .Unusual occurrences may include .Fall incident .The Nurse will .Assess the resident's condition .Notify the physician .Notify the resident's representative .Notify DON [Director of Nursing]/Administrator .Document in the nurse's note . Review of the facility's undated policy titled, Fall Prevention & Management Program, showed .A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level .The event may be witnessed, reported, or presumed .A near miss .is also considered a fall .When .resident experiences a fall, the facility will .Assess the resident .Complete a post-fall assessment .an incident report .Notify physician .family .Review the resident's care plan .update as…

  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 · D2024-04-11 · tag F0744 — failed to care for residents with dementia — isolated
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to develop a Dementia care plan for 1 resident (Resident #84) of 9 residents reviewed for Dementia Care. The findings include: Review of the facility's undated policy titled, Dementia Care, showed .The facility will .develop, and implement care plans through an interdisciplinary team (IDT) approach . Resident #84 was admitted to the facility on [DATE] with diagnoses including Dementia, Lack of Coordination, and Bipolar Disorder. Review of a History and Physical for Resident #84 dated 1/29/2024, showed .Past Medical History .Vascular dementia . Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #84 was cognitively intact. Resident #84 exhibited no behavioral symptoms. Active diagnoses included Non-Alzheimer's Dementia. Review of the comprehensive care plan for Resident #84 showed the resident was not care planned for Dementia. Review of the medical record for Resident #84…

  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 · D2024-04-11 · tag F0756 — failed to review each resident's drug regimen — isolated
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to ensure the physician or nurse practitioner acted upon a recommendation from the consultant pharmacist for 1 resident (Resident #27) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility's undated policy titled, Medication Regimen Review, showed .The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart .The pharmacist shall document, either manually or electronically, that each medication regimen review has been completed .The pharmacist shall document either that no irregularity was identified irregularities .The pharmacist shall communicate any irregularities to the facility in the following ways .Verbal communication to the attending physician, Director of Nursing, and/or staff of any urgent needs .Written communication to the attending physician, the facility's Medical Director, 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 · D2024-04-11 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure the medication error was less than 5 percent. There were 26 opportunities with 2 errors resulting in a 7.69% medication error rate. The errors involved 2 of 8 residents (Residents #20 and #92) in the sample. The findings include: Review of the facility's undated policy titled, MDI [Metered Dose Inhaler] Administration guidelines, showed .Instruct resident to exhale fully .to hold breathe and slowly count to ten .to slowly exhale through pursed lips .Repeat puffs as directed, waiting at least 1 (one) minute between puffs, or per manufacturer's specification . Review of the facility's undated policy titled, Medication Error Guidelines, showed .ensuring residents receive care and services safely in an environment free of .medication errors .'Medication error' means the observed or identified preparation or administration of medications .which is not is accordance with the prescriber's orders;…

  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

“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

$138,802 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $138,802 — penalty dated 2024-04-11
• Medicare payment denial — starting 2024-05-10 for 110 days

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 PLAINVIEW HEALTHCARE PARTNERS — 9 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 11 rows in the source record cover these 7 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.

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 $493K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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