Holston Rehabilitation And Care Center
3641 Memorial Blvd, Kingsport, TN 37664 · For profit - Corporation · 204 certified beds · (423) 246-2411 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0602), cited Nov 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,868 in federal fines (most recent 2025-11-17)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (68%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 24.1% | 14.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.3% | 6.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.0% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 12.2% | 13.8% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.0% | 3.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 26.7% | 17.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 43.8% | 31.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.3% | 5.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.5% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.6% | 16.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.7% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 97.4% | 79.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.4% | 22.6% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 21.6% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.92 | 1.67 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.41 | 1.56 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
44.2% 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 63 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 31.7% 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 60 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 0.37 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 44.2%CMS range 31.5–56.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.4%CMS range 6.1–13.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 31.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 33.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 33.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.8%CMS range 5.9–15.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.61 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 204 beds and averages 149.3 residents a day — about 73% occupied, or roughly 55 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 3.63 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 2.18 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 3.22 hrs/resident/day on weekends vs 3.79 on weekdays — 15% thinner on weekends. RN hours go from 0.55 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 68% 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 unchanged from the previous inspection. 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.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · Gcited before2025-11-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, facility investigation review, hospital record review, and interview, the facility failed to provide an environment that was as free of accident hazards as possible and provide adequate supervision to prevent accidents for 1 of 5 (Resident #166) residents reviewed for falls. Resident #166 had an unwitnessed fall, nursing staff failed to report the fall to the physician resulting in a 9-day delay in evaluation and Resident #166 was later diagnosed with a left hip fracture. The facility's failure resulted in actual Harm for Resident #166.The findings include: Review of the facility's policy titled, Change in Condition of Residents, dated 1/22/2024, revealed .notification of the physician, legal representative/family member should occur promptly when there is a change in condition .defined .an accident .which results in injury and has potential for physician intervention .accident or incidents resulting in suspected injury . Review of the medical record…
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.
- Potential for harm · E2025-11-17 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observations, and interviews, the facility failed to ensure the dumpster area was maintained in a clean and sanitary condition and garbage and refuse were properly contained in 3 of 3 dumpsters.The findings include:Review of the facility's policy titled, Disposal of Garbage and Refuse, dated 9/1/2024, revealed .Garbage and refuse .Surrounding area shall be kept clean so that accumulation of debris and insect/ rodent attractions are minimized .receptacles for refuse shall be maintained in good repair .During an observation with the Certified Dietary Manager (CDM) on 9/22/2025 at 11:50 AM, revealed the following: The 3 of 3 dumpsters were observed with the doors open. Around the dumpster area the following items were observed broken or in disrepair: 2 bed frames, 4 nightstands, 1 end table, 1 office chair, 1 toilet, 1 wheelchair, and 1 file rack. Continued observation revealed various garbage debris scattered on the outer right edge of the dumpster area. The CDM stated the broken items had been around the dumpster area for more than 2 weeks 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.
- Potential for harm · Ecited before2025-11-17 · tag F0880 — failed to prevent and control infections — patternProvide 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, observation, and interview, the facility failed to ensure appropriate Personal Protective Equipment (PPE) was donned for 2 residents (Resident # 25 and #37) of 25 residents observed for Enhanced Barrier Precautions (EBP) and the facility failed to wear face coverings during a COVID-19 outbreak on 5 of 5 hallways of 1 of 2 shifts.The findings include: Review of the facility's policy titled, Nursing Management Manual, effective 3/21/2024, revealed .implement Enhance Barrier Precautions (EBP) for the prevention of transmission of multidrug resistant organisms .all staff receive training on enhanced barrier precautions upon hire and annually .training in high risk activities .are expected to comply with all precautions .an order for enhanced barrier precautions will be obtained for .wounds .even if the resident is not known to be infected or colonized .PPE for enhanced barrier precautions .necessary when performing high contact care .activities include…
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.
- Potential for harm · D2025-11-17 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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, facility investigation review, personal file review, and interview, the facility failed to protect a resident's rights to be free from misappropriation and/or exploitation when money totaling $23.11 was taken from 1 resident (Resident #43) of 22 residents reviewed for misappropriation. The findings include:Review of the facility policy titled, Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation, undated, revealed .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including Hereditary and Idiopathic Neuropathy, Respiratory Disorders, and Muscle Wasting and Atrophy. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #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.
- Potential for harm · D2025-11-17 · tag F0644 — isolatedCoordinate 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 review of facility policy, review of medical record, and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASARR) timely after a new mental health diagnosis was added for 1 resident (Resident #10) of 8 residents reviewed for PASARR. The findings include:Review of the facility's policy titled, Resident Assessment-Coordination with Pre-admission Screening and Resident Review (PASARR) Program, undated, revealed .All applicants to this facility will be screened for serious mental disorders .ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later.Review of a PASARR Level 1 screen for Resident #10 dated 8/12/2025, revealed the resident had .no mental health diagnosis known or suspected.Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnosis including Encephalopathy, Diabetes, and Intraspinal Abscess and Granuloma. Continued review revealed the resident received a new…
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.
- Potential for harm · Dcited before2025-11-17 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 facility policy review, medical record review, observation, and interview, the facility failed to implement care plan interventions related to blood glucose checks for 1 resident (Resident #109) and falls for 2 residents (Resident #138 and #166) of 25 residents reviewed for care plans.The findings include: Review of the facility policy titled, Comprehensive Care Plans, dated 12/31/2024, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing.needs.and.services that are identified in the resident's comprehensive assessment and meet professional standards of quality.The comprehensive care plan will describe, at a minimum.The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the facility policy titled, Fall Prevention Program,…
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.
- Potential for harm · Dcited before2025-11-17 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 facility policy review, medical record review, observation, and interview the facility failed to revise the care plan for 2 residents (Resident #25 and Resident #100) of 25 residents reviewed for care plans.The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised 12/31/2024, revealed .policy of this facility to develop .implement .person-centered care plan for each resident .Individualized interventions for trauma survivors .care plan will be reviewed and revised . Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Diabetes, Muscle Wasting, and Orthopedic Aftercare. Review of the Physician Orders for Resident #25 dated 4/13/2025, revealed .enhanced barrier precautions for wound . Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #24 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review…
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.
- Potential for harm · Dcited before2025-11-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of medical records, and interviews, the facility failed to follow the Physician's Orders for blood glucose monitoring for 1 resident (Resident #109) of 5 residents reviewed for blood glucose monitoring.The findings include:Review of the facility's policy titled, Blood Glucose Monitoring, dated 1/1/2025, revealed .It is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders .The facility will perform blood glucose monitoring as per physician's orders .Verify the physician's order .Document the procedure .Review of the medical record revealed Resident #109 was admitted to the facility on [DATE] with diagnosis including Polyneuropathy, Osteomyelitis of Right Ankle and Foot, Diabetes, and Cellulitis of Right Lower Limb.Review of the Physician's Orders dated 7/23/2025, revealed Resident #109 had an order for accuchecks (blood glucose (sugar) monitoring) daily and as needed (PRN).Review of the Comprehensive Care Plan…
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.
- Potential for harm · D2025-11-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when 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 review of facility policy, review of the medical record, observation, and interview, the facility failed to follow a physician's order for oxygen therapy for 1 resident (Resident #56) of 5 residents reviewed for oxygen therapy and failed to document CPAP/BIPAP (Continuous Positive Airway Pressure/Bilevel Positive Airway Pressure) (machine that provides continuous positive airway pressure device used to keep the airway open during sleep], BIPAP [machine that provides bi-level positive airway pressure to keep the airway open during sleep) care for 1 resident (Resident #72) of 8 residents reviewed for CPAP/BIPAP. The findings include: Review of the facility policy titled, Oxygen Administration, dated 9/1/2024, revealed .Oxygen is administered to resident who need it, consistent with professional standards of practice.Oxygen therapy.is the administration of oxygen at concentrations greater than that in ambient air.with the intent of treating or preventing the symptoms and manifestations of hypoxia.Hypoxia…
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.
- Potential for harm · F2024-03-05 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on facility policy review, observation, and interview the facility failed to maintain sanitary kitchen equipment which had the potential to effect 120 of the 122 residents in the facility. The findings include: Review of the facility's undated policy titled, Cleaning and Sanitizing Dietary Areas and Equipment, showed .All kitchen areas and equipment shall be maintained in a sanitary manner and be free of build-up of food, grease, or other soil . During the initial kitchen observation on 3/3/2024 at 10:55 AM, with the Certified Dietary Manager (CDM), showed the facility's gas stove griddle had a layer of dried brownish-black food debris observed on the top and the right-side lip of the metal splashguard of the griddle. During an interview on 3/3/2024 at 11:12 AM, the CDM confirmed she was responsible for the oversight of the dietary department. The CDM stated the kitchen equipment was cleaned daily and deep cleaned weekly. The CDM confirmed the stove griddle was in an unsanitary condition and could use further cleaning.
- Potential for harm · D2024-03-05 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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
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 medical information was not visible for 3 residents (#1, #27, and #31) of 122 residents observed and failed to ensure 1 resident (Resident #47) was assisted to the smoking area of 7 residents reviewed for smoking. The findings include: Based on the facility's undated policy titled, Resident Dignity, showed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .Maintain resident privacy . Review of the facility's undated policy titled, Resident Rights, showed .The resident has a right to reside and receive services in the facility with reasonable accommodation of resident needs . Resident #1 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Depression, Dementia, Atrial…
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.
Show the remaining 12 citations
- Potential for harm · D2024-03-05 · tag F0641 — isolatedEnsure 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 Resident #1 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Hemiplegia, Asthma, Depression, Dementia, Atrial Fibrillation, Hypertension, and Peripheral Vascular Disease. Review of a quarterly MDS assessment dated [DATE], showed Resident #1 had an active diagnosis of Septicemia (infection of the bloodstream). During an interview on 3/3/2024 at 12:30 PM, LPN #3 stated Resident #1 was not receiving antibiotics for Septicemia. During an interview on 3/4/2024 at 10:30 AM, the MDS Coordinator stated Resident #1 was inaccurately coded on the MDS dated [DATE] for the active Septicemia diagnosis. During an interview on 3/4/2024 at 3:20 PM, the DON stated Resident #1 had not been treated for Septicemia. The DON reviewed the resident's medical record and stated the resident had not been treated for Septicemia in the 7 day look back period for the MDS dated [DATE]. The DON confirmed Resident #1's MDS assessment dated [DATE] had been coded inaccurately for Septicemia. During an…
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.
- Potential for harm · Dcited before2024-03-05 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 Resident #100 was admitted to the facility on [DATE] with diagnoses including Hemiplegia following a Cerebral Infarction, Aphasia, and Nontraumatic Intracerebral Hemorrhage. Review of an Activities Initial Review assessment dated [DATE], showed Resident #100 had no preference to participate in spiritual activities, and the resident did not wish to have clergy visits. Review of an admission MDS assessment dated [DATE], showed Resident #100 was severely impaired for decision making. Review of Resident #100's comprehensive care plan dated 1/9/2024, showed .spiritual distress .consult clergy as needed .determine resident's religion affiliation .determine spiritual beliefs regarding death .encourage [the] resident to continue to study spiritual beliefs . Review of Resident #100's Activity Attendance Record dated 2/18/2024 thru 3/4/2024, showed the resident had attended a spiritual activity on 2/22/2024 and 2/29/2024. During an observation and family interview on 3/3/2024 at 11:47 AM, Resident #100 was observed in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-05 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 facility policy review, medical record review and interviews, the facility failed to include the resident or resident's representative in the care planning process for 1 resident (Resident #106) of 28 residents reviewed for care planning. The findings include: Review of the facility's policy titled, Person Centered Care Plans, dated 12/18/2023, showed .According to federal regulations, the facility develops a comprehensive person centered plan of care for each resident .Conducting the Interdisciplinary Person Centered Care Plan Meeting .including the resident and their representative when possible .Existing goals and approaches should be reviewed and revised .When the resident is unable to participate in the care plan meeting .due to .cognitive impairment .the residents [resident's] family members should be encouraged to attend .Family participation should be recorded in the EMR [electronic medical record] . Resident #106 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, observations, and interview the facility failed to provide a safe environment by leaving medications unsecured at the bedside for 1 resident (Resident #419) of 28 residents observed. The findings include: Review of the facility policy titled, Medication Storage in the Facility, dated 1/2/2024, showed .Except for those requiring refrigeration or freezing, medications for internal use are stored in a medication cart or other designated area . Review of the facility policy titled, Preparation and General Guidelines .Self-Administration of Medications, dated 1/2/2024, showed .If the resident demonstrates the ability to safely self-administer medications, a further assessment of safety of bedside medications storage is conducted . Review of Resident #419's Medication Review Report showed the resident admitted to the facility on [DATE] with an order for Spiriva Handihaler Inhalation Capsules 18 microgram (mcg) inhale orally one time a day. There was not an order…
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.
- Potential for harm · D2024-03-05 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 accurately transcribe an admission order for 1 resident (Resident #48) of 3 residents reviewed for admission orders and the facility failed to ensure admission assessments were accurate for 1 resident (Resident #364) of 28 sampled residents. The findings include: Review of the facility's policy titled, Nursing Assessments, dated 12/18/2023, showed .information in the medication record, as documented by nursing personnel aids in the development of accurate plan . Review of the facility's policy titled, Medication Reconciliation, dated 1/25/2024 .Medication reconciliation refers to the process of verifying that the resident's current medication list matches the physician's orders for the purpose of providing the correct medications to the resident at all points throughout his or her stay .Medication reconciliation involves collaboration with the resident/representative and multiple disciplines, including…
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.
- Potential for harm · D2024-03-05 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility contract review, facility policy review, medical record review, and interview, the facility failed to ensure a coordinated plan of care with the hospice provider was available in the medical record for 1 (Resident #60) of 4 residents reviewed for hospice. The findings include: Review of the facility's hospice contract with Resident #60's hospice provider dated 4/11/2018, showed .Plan of Care .the Skilled Nursing Facility shall provide services in accordance with the Hospice plan of care . Resident #60 was admitted to the facility on [DATE] and readmitted from the hospital on 1/22/2024 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Complete Traumatic Amputation at Level Between Left Hip and Knee, Asthma, Diabetes Mellitus, Atrial Fibrillation, Hypertension, and Post Traumatic Stress Disorder. Review of the facility's policy titled, Hospice, dated 5/15/2023, showed .policy of this facility to provide and/or arrange for hospice…
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.
- Potential for harm · Dcited before2024-03-05 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 assist 4 residents (Residents #20, #75, #614, and #39) with hand hygiene before meals on 1 of 5 hallways observed for meal service. The findings include: Review of the facility's policy titled, Nursing Procedures Manual, dated 6/1/2023, showed .Basic Care Procedures .Serving a Meal .Prepare .serving area for mealtime and make sure hands .are clean . Resident #20 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, Chronic Obstructive Pulmonary Disease, and Anxiety Disorder. Review of a quarterly Minimum Data (MDS) assessment dated [DATE], showed Resident #20 had moderate cognitive impairment. During an observation on 3/3/2024 at 12:02 PM, Resident #20 was served the lunch meal and staff did not offer or assist the resident with hand hygiene. Resident # 75 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Chronic Kidney Disease, and Anxiety Disorder.…
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.
- Potential for harm · Dcited before2024-03-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, medical record review, and interview, the facility failed to ensure physician orders were followed for 1 resident (Resident #48) of 28 residents reviewed. The findings include: Review of the facility's policy titled, .Medication Administration-General Guidelines ., dated 1/2/2024, showed .Medications are administered as prescribed in accordance with good nursing principles and practices .FIVE RIGHTS-Right resident, right drug, right dose, right route and right time are applied for each medication being administered .The medication administration record [MAR] is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's .[MAR] are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for 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.
- Potential for harm · D2023-11-09 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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, review of the facility investigation and interview, the facility failed to ensure facility staff did not assume the possession and control of a resident's personal property, for 1 resident (Resident #3) of 5 residents reviewed. The findings include: Review of the facility employee handbook, undated, titled HOLSTON MANOR ASSOCIATE HANDBOOK showed .The policies in this handbook are to be considered guidelines .Personal Property of the Residents .Only your immediate Supervisor, Director of Nursing or Administrator may assume, even temporarily, the possession or control of resident's personal property, and then only for the purpose of putting it in a safe place and issuing receipts . Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Schizophrenia, Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) assessment. dated 9/25/2023, showed Resident #3's…
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.
- Potential for harm · D2020-01-14 · tag F0553 — failed to let residents help plan their care — isolatedAllow 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 facility policy review, record review, observations, and family and staff interviews, the facility failed to ensure a resident and representative participated in the development and implementation of a person-centered plan of care for 1 of 12 residents (Resident #336), which had the potential to result in unmet care needs. The findings include: Review of the facility policy titled, Care Planning-Welcome Meeting, dated 2/2019, showed that an initial meeting with the resident and/or representative and the interdisciplinary team will be conducted within 96 hours of admission to review initial goals, plan of care, discharge plans and to introduce key facility team members. Review of the medical record, showed Resident #336 was admitted to the facility on [DATE] with a diagnosis of Aftercare for Right Femur Fracture. Observation of the resident's room on 1/12/2020 at 12:01 PM, showed Resident #336 sitting in a recliner and Family Member #1 at chairside. When asked if he participated in his care, Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-01-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, record review, observation, and resident and staff interview the facility failed to follow physician's orders for wound care for 1 resident of 3 residents reviewed for wounds (Resident #286) which resulted in an unmet care need. The facility failed to update the monthly physician's recapitulation orders to reflect a change in the resident's code status for 2 of 32 sampled residents (Resident #30 and #125), which had the potential to result in the facility not following the resident's preference in code status. The findings include: Review of the facility policy titled, Wound Care, dated 10/2010, showed verify there is a physician's order for this procedure. Review of the medical record, showed Resident #286 had a diagnosis of Peripheral Vascular Disease, Venous Insufficiency (Chronic) (Peripheral), Venous Ulcer to Right Medial Ankle and Arterial Ulcer to Left Lateral Foot. Review of the Physician's orders dated [DATE] showed .Clean area to venous right medial ankle with NS…
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.
- Potential for harm · D2020-01-14 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — the official record, unedited, may be distressing
Based on medical record review, and staff interview, the facility failed to obtain laboratory services as ordered by the physician for 1 of 5 residents sampled (Resident #103), which had the potential to result in unmet care needs. The findings include: Review of the medical record showed Resident #103 had diagnoses including Disorders of Plasma-Protein Metabolism, Abnormal Weight Loss, and Anemia. Review of the medical record, showed a Physician's Order dated 12/10/2019 for a Pre-Albumin level (a laboratory test to determine the amount of protein in the blood). Medical record review showed no documentation of the Pre-Albumin level laboratory result. During an interview conducted on 1/13/2020 at 2:30 PM, the Director of Nursing confirmed the Pre-Albumin level ordered by the physician on 12/10/2019 for Resident #103 was not available and had not been obtained by the facility.
“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.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$10,868 in federal fines across 1 penalty.
- $10,868 — penalty dated 2025-11-17
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 VENZA CARE MANAGEMENT — 25 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.4 | -1.4 vs chain |
| Health inspection | 2 of 5 | 2.4 | -0.4 vs chain |
| Staffing | 1 of 5 | 2.9 | -1.9 vs chain |
| Quality measures | 2 of 5 | 2.8 | -0.8 vs chain |
The other 24 homes this chain runs (chain average 2.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FH SNF OPERATIONS HOLDING LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2022 |
| CH FH HOLDING LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 03/25/2026 |
| CW FH HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 03/25/2026 |
| M MELB OPCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 12/01/2025 |
| M MELB OPCO TRUST | Organization | INDIRECT OWNERSHIP INTEREST | — | since 12/01/2025 |
| MS FH HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 01/01/2022 |
| S MELB OPCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 12/01/2025 |
| S MELB OPCO TRUST | Organization | INDIRECT OWNERSHIP INTEREST | — | since 12/01/2025 |
| SE SNF ASSOCIATES LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 03/25/2026 |
| SE SNF ASSOCIATES TRUST | Organization | INDIRECT OWNERSHIP INTEREST | — | since 03/25/2026 |
| SE SNF HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 03/25/2026 |
| SE SNF HOLDINGS TRUST | Organization | INDIRECT OWNERSHIP INTEREST | — | since 03/25/2026 |
| SS FH HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 01/01/2022 |
| GOODMAN, MENUCHA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2025 |
| FH OPCO MANAGER LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2022 |
| MELB OPCO MANAGER LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2025 |
| VERTEX FINANCIAL SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| KELLY, JOHNATHAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/14/2024 |
| THEERATHORN, PITCHAR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/30/2025 |
| HERZKA, YISROEL | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/14/2026 |
| STRAUSS, SUSAN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/30/2025 |
CMS files one row per role, so the 28 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted.
16 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.
This home reported $711K 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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Tennessee Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 445295. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.