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Wexford House

2421 John B Dennis Highway, Kingsport, TN 37660 · For profit - Corporation · 174 certified beds · (423) 288-3988 Medicare & Medicaid certified

Call the home — (423) 288-3988 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0609) — most recent Nov 2025
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (65%) 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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2421 N John B Dennis Hwy · (423) 288-3988 · Call to confirm hours
Pharmacy
1903 Brookside Dr · (423) 390-1064 · Call to confirm hours
Grocery
Kroger0.6 mi
1664 E Stone Dr · (423) 392-0844 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
2409 N John B Dennis Hwy · (423) 288-2721

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 5 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 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased16.0%14.0%15.4%typical
Long-stay residents who lose too much weight10.4%6.1%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection1.0%1.8%2.0%better
Long-stay residents with depressive symptoms0.7%13.8%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.6%0.1%0.1%worse
Long-stay residents with falls causing major injury2.3%3.4%3.3%better
Long-stay residents whose ability to walk worsened27.2%17.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication11.0%31.7%18.9%better
Long-stay residents given the seasonal flu vaccine97.4%94.5%95.3%typical
Long-stay residents with pressure ulcers4.3%5.0%4.7%typical
Long-stay residents with worsening bladder/bowel control12.1%20.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.0%16.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.7%1.4%better
Short-stay residents given the seasonal flu vaccine70.3%79.8%79.4%worse
Short-stay residents rehospitalized after admission36.0%22.6%22.6%worse
Short-stay residents with an outpatient ER visit17.2%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.631.671.67typical
Long-stay outpatient ER visits per 1,000 resident days0.701.561.80better

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

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

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

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

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

54.2% 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 31 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.2%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
35.0%U.S. median 56.6%
Met the expected recovery
0.34U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 35.0% 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 20 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 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF54.2%CMS range 38.7–69.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 6.3–15.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge35.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge45.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge20.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.871.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.60
RN hours/ resident / day
0.67
LPN hours/ resident / day
1.77
Aide hours/ resident / day
3.04
Total nurse hours/ resident / day
0.47
RN hoursweekends
65.0%
Total nursing turnover
70.0%
RN turnover

How full it usually is: this home is certified for 174 beds and averages 123.3 residents a day — about 71% occupied, or roughly 51 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 3.04 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.77 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.72 hrs/resident/day on weekends vs 3.17 on weekdays — 14% thinner on weekends. RN hours go from 0.65 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 65% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2025-06-18)
6
at the previous standard inspection (2024-03-20)

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

Inspection deficiencies

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

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.

  • Potential for harm · D2025-11-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, medical record review, review of facility investigation and interview, the facility failed to report an allegation of abuse to the State Survey Agency for 1 resident (Resident #1) of 5 residents reviewed for abuse. The findings include: Review of the facility's undated policy titled Abuse, Neglect, and Exploitation revealed .it is the policy of this facility to provide .procedures that prohibit and prevent abuse .Abuse .includes .mental abuse including abuse facilitated or enabled through the use of technology .The facility will designate an Abuse Coordinator in the facility who is responsible for reporting allegations or suspected abuse .to the state survey agency .The facility Abuse Coordinator will be the Administrator . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Lumbar Spina Bifida, Neuromuscular Dysfunction of Bladder, and Artificial Opening of Urinary Tract, the resident discharged to a hospital on…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-18 · tag F0802 — failed to prepare enough nourishing food — pattern
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documentation, observation, and interview, the facility failed to employ staff with the appropriate competencies to maintain and ensure manufacturers guidelines were followed for testing of chemical sanitation for dishwasher use. The findings include: Review of the facility's Dishmachine Temperature Record (Low Temperature Machine) for the month of 6/2025, revealed chlorine rinse recordings of 50 were documented each day, 6/1/2025 - 6/13/2025 for the breakfast, lunch and dinner meals. During an observation on 6/16/2025 at 10:43 AM, the Certified Dietary Manager (CDM), was observed having difficulty reading the strips. The CDM asked this surveyor how to read the strip, then asked .what is it supposed to read .? The CDM asked Dietary Aide A, to test the chemical results in the rinse cycle and instructed Dietary Aide A to place on water spots on the pan. During an observation on 6/16/2025 at 10:44 AM of the QT-10 Hydrion container guide for testing strips for the parts per million (ppm), revealed 0, 100, 200, 300 and 400 however, a reading of 50 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-18 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, observation, and interview, the facility failed to ensure kitchen cooking equipment was maintained in a clean and sanitary condition and food was stored, prepared, and served under sanitary conditions which had the potential to affect 80 of 81 residents. The findings include: Review of the facility's undated policy titled, Pots and Pans-Sanitizing, revealed .scrape food particles form [from] pots and pans .scrub pots and pans .rinse pots and pans free .store in proper storage area . Review of the facility's work order for ice machine maintenance revealed the ice machine was cleaned 2 times per year. During an observation of the ice machine on 6/16/2025 at 9:56 AM, revealed a black substance on the rim of a white panel above and touching the ice contained in the ice machine. During an observation of the hand washing area on 6/16/2025 at 9:58 AM, revealed no paper towels in the dispenser. During an observation and tour of the kitchen with the Certified Dietary Manager (CDM) on 6/16/2025 at 10:00 AM, revealed the following: 1. Large barrel trash can…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-18 · tag F0813 — pattern
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    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, observations, and interviews, the facility failed to ensure resident personal refrigerator logs were kept up to date and temperatures were within facility policy recommendations, and failed to ensure expired foods were not available for resident use for 5 residents (Resident #17, #39, #51, #58, and #64) of 11 resident refrigerators observe. The findings include: Review of the facility's undated policy titled, Resident Refrigerators, revealed .refrigerators are allowed in a resident's room under the following conditions: refrigerator maintains proper temperatures .facility staff shall record refrigerator temperatures daily on a temperature log .temperatures will be below 41 [degrees] [Fahrenheit] [(F)] .foods with use-by dates shall be discarded accordingly . Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Hemiplegia, Muscle Weakness, Diabetes, and Chronic Kidney Disease. Review of an annual…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-18 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, and interviews, the facility failed to provide a homelike environment for 1 resident (Resident #19) of 81 residents reviewed for a homelike environment. The findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of Hemiplegia, Dysphagia, and Intracranial injury. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 was severely impaired of cognitively skills of daily decision making. During an observation on 6/16/2025 at 11:28 AM, in Resident #19's room, revealed a large piece of wallpaper was missing from the wall beside Resident #19's bed. Further observation revealed a large area of missing paint from the wall beside the head of the resident's bed. Continued observation revealed the wallpaper was peeling away from the baseboard on the wall by the window. During an observation and interview in Resident #19's room on 6/18/2025 at 10:37…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, and interviews, the facility failed to develop a person-centered care plan related to tobacco use for 1 resident (Resident #14) of 21 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Care Plan/ Comprehensive Assessment, dated 4/4/2025, revealed .residents will have a comprehensive assessment that determines their functional status, strengths, weaknesses, needs/ preferences .care plan must .includes .initial goals .any services and treatments to be administered . Review of the medical record revealed Resident #14 was admitted to facility on 5/9/2023 with diagnoses including Diabetes, Chronic Kidney Disease, and Hypertension. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed Resident #14 used tobacco products.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-18 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, review of the facility's Narcotic (a category of perception-altering or sensory-dulling drugs that are regulated in schedules according to their abuse risk with schedule 1 being the highest abuse risk and 5 being the lowest abuse risk) Destruction Logs (form containing the name of a resident and the name of a controlled medication with the number of tablets remaining), and interview, the facility failed to follow the facility policy regarding the disposition and destruction of narcotics. The findings include: Review of the facility policy titled, Destruction of Unused Drugs, undated, revealed .The actual destruction of drugs conducted by our facility must be witnessed by the consultant pharmacist and one of the following individuals: a. An agent of the State Board of Pharmacy; b. The facility administrator; or c. The director of nursing services . Review of Narcotic Destruction Logs dated [DATE] to [DATE], revealed the Narcotic Destruction Log provided a listing of the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-18 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure proper infection control practices related to hand hygiene were followed during meal service when the staff failed to offer hand hygiene assistance to 3 residents (Resident #178, Resident #34, and Resident #16) of 10 residents observed during meal tray distribution on 1 of 4 hallways. The findings include: Review of the facility's undated policy titled, Hand Hygiene, revealed .all staff will perform proper hand hygiene procedures to prevent the spread of infection .hand hygiene is indicated and will be performed under the conditions listed in .the attached hand hygiene table .[hand hygiene table] condition .before and after eating . Review of the medical record revealed Resident #178 was admitted to the facility on [DATE] with diagnoses including Pelvis Fracture, Chronic Kidney Disease, and Anemia. Review of the comprehensive care plan for Resident #178 revised 5/26/2025, revealed .self-care…

    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 · Fcited before2024-03-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, observations, and interview, the facility failed to ensure kitchen cooking equipment was maintained in a sanitary condition which had the potential to affect 82 of 86 residents. The findings include: Review of the facility's undated policy titled, Pots and Pans-Sanitizing, showed .scrape food particles form [from] pots and pans .scrub pots and pans .rinse pots and pans free .store in proper storage area . Review of the facility's undated policy titled, Sanitization of Equipment, showed .wipe up spills .using clean sanitizing solution .wash .inside and outside and front .scrub interior and exterior .door frames .hinge areas . During an observation of the clean dish storage area on 3/18/2024 at 10:15 AM, with the Food Service Manager (FSM), showed one large sheet pan with crusty, greenish-brown food debris present to outer edge of the pan. During an observation of the cooking area on 3/18/2024 at 10:25 AM, with the FSM, showed the following: -Hot food holding cabinet had dried, black, greasy food debris present around the door handle and on the bottom,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-20 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observations, and interviews, the facility failed to ensure staff maintained residents' dignity when residents were served milk products in disposable cartons for 9 residents (Residents #20, #84, #6, #18, #19, #23, #33, #43, and #85) on 3 of 5 hallways observed for meal tray distribution and failed to maintain resident's dignity during feeding for 1 resident (Resident #29) of 3 residents observed for feeding. The findings include: Review of the facility's policy titled, PATIENT/RESIDENT RIGHTS, revised on 7/14/2023, showed .All persons involved in the care of a patient/resident shall respect and support the patient/resident's right to competent, considerate, and courteous treatment or service within our capacity . Review of the facility's policy titled, Dining, revised on 12/2023, showed .The dining experience will be safe and satisfying for the resident .Seating promotes sociable, friendly dining .Residents are assisted in a dignified and timely manner . Review of the facility'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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 5 citations
  • Potential for harm · D2024-03-20 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, review of the Resident Assessment Instrument (RAI) Manual 3.0, medical record review, observations, and interviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 residents (Residents #78 and #56) of 20 residents reviewed for MDS assessments. The findings include: Review of the RAI Manual 3.0 dated 10/1/2023 showed . primary purpose as an assessment instrument is to identify resident care problems that are addressed in an individualized care plan .the assessment [MDS] accurately reflects the resident's status .registered nurse conducts or coordinates each assessment .One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status .Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, mood or behavior status, medical treatments, nursing monitoring .during the 7-day look-back period .Check the following information…

    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 · D2024-03-20 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interviews, the facility failed to include 1 resident (Resident #31) in the care planning process of 20 residents reviewed for care planning. The findings include: Review of the facility's policy titled, Interdisciplinary Care Conference Guidelines, dated 2/2024, showed .Interdisciplinary Care Conference is held to develop/review the plan of care based upon the comprehensive assessment .includes .Resident and family concerns .Care Conference .may be held whenever the team feels it is necessary to review the plan of care .the following should have representation at the meeting .resident .is informed and invitations are sent to resident .as appropriate prior to the conference date . Social Services documents the attempt to include or set up meeting in the resident's record .Social Services will schedule .care conference . Resident #31 was admitted to the facility on [DATE] with diagnoses including Pneumonia, Arthritis, and Diabetes Mellitus. Review of a…

    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 · D2024-03-20 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation, and interview, the facility failed to ensure expired supplies were not available for resident use in 1 medication cart (300 long hall cart) of 3 medication carts observed. The findings include: Review of the facility's policy titled Storage of Medical Supplies and Medication, dated 2/2024, showed . No discontinued, outdated, or deteriorated medical supplies/medications are available for use in the facility. All such .and medical supplies disposed of in accordance to federal, state regulations, and facility policies as well as manufacturer's guidelines. During an observation and interview of the 300 long hall medication cart on [DATE] at 7:55 AM, with Licensed Practical Nurse (LPN) #1, showed 1 package of two cotton swabs expired [DATE], 1 speimen collection swab kit expired [DATE], 3 vacuum blood draw vials expired [DATE], and 1 blood draw vial expired [DATE] were observed in a cardboard box in the drawer of the medication cart. LPN #1 stated .I don't know why those…

    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 · D2024-03-20 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose 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 garbage and refuse were properly contained in 2 of 2 dumpsters (dumpster #1 and #2). The findings include: Review of the facility's undated policy titled, Garbage and Trash Cans, showed .waste must be placed in covered garbage and trash cans . Review of the facility's policy titled, Home-like Environment, dated 12/2023, showed .refuse containers provided for an area shall have tight-fitting covers . During an observation on 3/18/2024 at 10:35 AM, of the outside dumpster area, with the Food Service Manager (FSM), showed 2 dumpsters were present for waste disposal. The hard, plastic roof covering dumpster #1 was open and dumpster #2's sliding door on the right side of the dumpster was open. Dumpster #1 and #2's contents were open to air, elements, and had the potential exposure to pests. During an interview on 3/18/2024 at 10:40 AM, the FSM stated the dumpster #1's roof and dumpster #2's sliding door should have been tightly closed to prevent the exposure to elements and potential rodents.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2020-02-20 · tag F0604 — failed to not use physical restraints improperly — pattern
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 interview, the facility failed to identify and assess restraint use for 3 of 6 residents (Resident #5, #77, and #115) reviewed for restraints. The findings include: Review of the facility policy titled, Restraints, dated 10/2019, showed .Physical restraints include, but are not limited to .soft ties . the resident cannot remove easily .Using side rails that keep a resident from voluntarily getting out of bed .Using devices in conjunction with a chair, .belts, that the resident cannot remove easily, that prevent the resident from rising .Restraint use will be assessed by the interdisciplinary team at least quarterly for elimination, reduction or continued need based on resident's condition . Review of the medical record, showed Resident #5 was admitted to the facility on [DATE] with diagnoses including Dementia, Bronchitis, Anemia, Hypothyroidism, and Convulsions. Review of a Physician's orders dated 2/1/2020-2/29/2020 showed .soft belt to be used .…

    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

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to AHAVA HEALTHCARE — 16 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.4-1.4 vs chain
Health inspection 2 of 52.6-0.6 vs chain
Staffing 1 of 52.1-1.1 vs chain
Quality measures 3 of 53.2-0.2 vs chain
The other 15 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 / managerTypeRoleSince
WEXFORD OPERATIONS GROUP HOLDCO LLCOrganizationDIRECT OWNERSHIP INTERESTsince 05/01/2025
BALLAD HEALTHOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 05/01/2025
BHO OPERATING GROUP LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 05/01/2025
BLUE RIDGE MEDICAL MANAGEMENT CORPORATIONOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 05/01/2025
MOUNTAIN STATES HEALTH ALLIANCEOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 05/01/2025
LABIN, SHIYAIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 05/01/2025
NEUMAN, BENJAMINIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 05/01/2025
NIEDERMAN, ANSHELIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
WEXFORD REALTY GROUP LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 05/01/2025
AHAVA HC LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
RUSEK, MICHELEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
WAYT, MARTAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025

CMS files one row per role, so the 24 rows in the source record cover these 12 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.

7 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.

$9.4M
Net patient revenuemost recent cost report
-50.9%
Operating marginrevenue minus expenses
$1.4M
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 65%Medicare 3%Other / private 33%

This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$449per resident / day
operating cost
$13,654per month
≈ monthly operating cost
$298per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TN

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Tennessee Medicaid page.

Typical monthly cost in Tennessee
$9,429/mo
Nursing home (semi-private)
$10,038/mo
Nursing home (private)
$5,845/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 445207. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-18, 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.

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