Creekview Health And Rehabilitation
3300 Broadway NE, Knoxville, TN 37917 · For profit - Corporation · 91 certified beds · (865) 686-7300 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (67%) runs well above the national median (45%)
- about 25% of its spending goes to commonly-owned related companies
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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 improved from 2 to 3 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 | 8.4% | 14.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.4% | 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 | 0.0% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 20.8% | 13.8% | 6.5% | worse 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 | 0.0% | 3.4% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 10.8% | 17.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.3% | 31.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 90.6% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.0% | 5.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.3% | 20.0% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.8% | 16.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.7% | 1.7% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 88.6% | 79.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.4% | 22.6% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 0.0% | 11.2% | 12.0% | check this* — see note marked star below the table |
| Long-stay hospitalizations per 1,000 resident days | 1.21 | 1.67 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.19 | 1.56 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
50.0% 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 43 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 46.9% 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 32 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 63% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
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 | 50.0%CMS range 36.5–62.9 | 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 | 11.5%CMS range 7.9–16.2 | 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 | 46.9% | 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 | 31.2% | 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 | 12.5% | 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 | not 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 stay | 0.0% | 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 | 1.7% | 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 | 6.3%CMS range 3.4–10.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 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 91 beds and averages 75.4 residents a day — about 83% occupied, or roughly 16 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 3.37 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 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 2.82 hrs/resident/day on weekends vs 3.59 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.71 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 67% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · Fcited before2025-11-17 · 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 — an excerpt from the official record, may be distressing
Based on facility policy review, observations, and interviews, the facility failed to ensure two dietary aides had a protective facial hair covering while working in the kitchen, failed to ensure food items were properly labeled (name, date opened, or expiration date), failed to ensure frozen food items were stored at a temperature for frozen food items to remain frozen solid which had the potential to affect 71 of 72 residents, and failed to ensure an expired nutritional supplement was discarded and unavailable for resident use on 1 of 2 medication carts observed.The findings include:Review of the facility's policy titled, Sanitary Standards-Dietary Personnel, revised 7/2016, revealed .It is the policy of this facility .dietary personnel will be required to follow additional sanitary standards .Hair restraints .beard restraint .must be worn at all times while in the kitchen .Review of the facility's policy titled, Food Storage, revised 8/2019, revealed .It is the policy of this facility .Foods shall be labeled, dated .Dates used may be a date prepared/opened and/or used by date…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-17 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to ensure 1 resident (Resident #19) was treated with dignity during feeding assistance of 7 residents observed for dining.The findings include:Review of the facility's policy titled, Resident Rights, undated, revealed .You have the right to be treated with dignity and respect in a manner that promotes or enhances your quality of life .Resident #19 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, Spastic Quadriplegic Cerebral Palsy, and Dementia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #19 was dependent on staff for eating. Review of the comprehensive care plan for Resident #19 revised 6/30/2025, revealed .ADL [Activities of Daily Living] Self Care Performance Deficit r/t [related to]…
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 (PASRR) after the resident was admitted to the facility with a mental health diagnosis for 1 resident (Resident #11) of 8 residents reviewed for PASRR. The findings include:Review of the facility's policy titled, PASRR Policy and Procedure Program, undated, revealed .To ensure compliance with federal and state regulations regarding the .PASRR process for individuals seeking admission .particularly those with serious mental illness (SMI), Intellectual disability (ID), or related conditions (RC) .policy applies to all admissions to the SNF [Skilled Nursing Facility] .Resident Review .conducted when there is a .change in the resident's condition .may trigger a new PASRR evaluation.Review of a PASRR Level I Screen for Resident #11 dated 3/3/2020 (submitted prior to admission to the facility), revealed the resident had .Anxiety Disorder .Psychotropic Medications…
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 on review of the facility policy, record review, observations and interviews, the facility failed to develop a comprehensive person-centered care plan for 1 resident (Resident #82) of 19 residents reviewed for care plans.The findings include:Review of the facility policy titled, Comprehensive Person-Centered Care Planning, dated 12/2023, revealed .facility.shall develop a comprehensive person-centered care plan for each resident that includes.information necessary to properly care for each resident.Review of the medical record revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including Pressure Ulcer of Sacral Region Stage 4, Chronic Hepatitis C, and Herpes Viral Infection of Urogenital System. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #82 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident had a pressure ulcer and viral…
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 F0761 — failed to label and store drugs safely — isolatedEnsure 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 review of the facility policy, review of manufacturer guidelines, medical record review, observations, and interviews the facility failed to ensure insulin medication was labeled appropriately to include an open date for 2 residents (Resident #46 and Resident #23) and failed to ensure eye medication was labeled appropriately to include an open date for 1 resident (Resident #67) of 3 residents reviewed for medication administration on 1 medication cart of 2 medication carts observed.The findings include:Review of the facility's policy titled, Medication Labeling and Storage, dated 2001, revealed .The nursing staff is responsible for maintaining medication storage .in a .safe .manner .Medications are stored .and are labeled accordingly .Review of the manufacturer guidelines, undated, revealed .HOW SUPPLIED/STORAGE AND HANDLING .Storage Conditions for TRESIBA FlexTouch [Degludec] [medication used to treat diabetes] .In-use (opened) .Room Temperature .56 days .Storage conditions for .NovoLog [Insulin…
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 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 review of the facility policy, medical record review, observations and interviews the facility failed to ensure staff followed infection control guidelines during wound care for 1 resident (Resident #44) of 3 residents reviewed for wounds. The findings include:Review of the undated facility policy titled, Wound Care, revealed .Put on exam glove. remove dressing .Pull glove over dressing and discard.sanitize hands.put on gloves .Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Dementia, and Hypertension. Review of the Physician's Orders for Resident #44 dated 4/26/2025, revealed .cleanse sacrum with normal saline, pat dry, apply calcium alginate and collagen particles to wound bed and cover with foam dressing three times per week and as needed.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #44 scored 00 on the Brief Interview for Mental Status (BIMS)…
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 · F2022-06-28 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 Assessment, review of facility's daily staffing sheets, review of facility shower schedules, medical record review, and interview, the facility failed to provide adequate staffing on the weekends to meet the needs of residents in the facility for 2 months (May and June 2022), which had the potential to affect all residents in the facility. The findings include: Review of the Facility Assessment updated 4/25/2022, showed the average daily census was 60. Licensed nurses and Certified Nurse aides (CNA) providing direct care total number needed or average range correlates to census number; staff will be assigned to meet needs of all residents. Review of the facility assignment sheets dated 5/1/2022-5/31/2022 and 6/1/2022-6/27/2022 showed the facility had fewer CNA's working on the weekends. Review of the facility's shower schedule revised 6/15/2022, showed Resident #29 was to receive a shower on Wednesday and Saturday on dayshift (7:00 AM- 3:00 PM). Review of Resident #29's shower…
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 · Fcited before2022-06-28 · 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 — an excerpt from the official record, may be distressing
Based on facility policy review, observation, and interview, the facility failed to properly store frozen foods in 1 of 1 freezer, failed to date 3 containers of dried foods in the kitchen area, and failed to maintain proper temperatures in 2 of 2 nourishment refrigerators, potentially affecting 58 of 60 residents in the facility. The findings include: Review of the facility policy titled, Food Storage-Dry Goods, dated 10/2019, showed .The Dining Services Director or designee ensures .the storage .date marked as appropriate . Review of the facility policy titled, Food Storage .Cold, dated 10/2019, showed .all food items are stored properly .arranged in a manner to prevent cross contamination . During an observation of the walk-in freezer on 6/26/2022 at 9:20 AM, with the Regional Director of Dietary Services revealed the following: 1. A 2-pound bag of peas, spilled in the box and open to air with freezer burn (covered in ice crystals). 2. An 8-pound ribeye open to air with freezer burn. 3. 15 4-ounce chicken breasts open to air with freezer burn. 4. 14 fish fillets open to air with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-06-28 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 review of the facility policy, medical record review, observation, and interview, the facility failed to develop a comprehensive care plan to include a urinary catheter for 1 resident (Resident #12), to include Activities of Daily Living (ADL) for bathing for 4 residents (Residents #14, #29, #52, and #210), and to include use of psychotropic medications for 1 resident (Resident #35) of 20 residents reviewed for care plans. The findings include: Review of the facility policy titled, Comprehensive Care Plans, dated 1/2/2020, revealed .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, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS [Minimum Data Set] assessment .…
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 · E2022-06-28 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, facility shower schedule review, and interview, the facility failed to provide scheduled showers for 4 residents (Residents #14, #29, #52, and #160) of 10 residents reviewed for showers. The findings include: Review of the facility policy titled, Bathing a Resident, dated 1/2/2020, showed .It is the practice of this facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues . Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Obstructive pulmonary Disease, Hypertension, Repeated Falls, and Abnormalities of Gait and Mobility. Review of Resident #14's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated the resident was cognitively intact. She was totally dependent with one staff member assistance for bathing. Review of the facility's shower schedule…
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 13 citations
- Potential for harm · Dcited before2022-06-28 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to complete a comprehensive resident admission assessment within 14 calendar days after admission for 1 resident (Resident #1) of 20 residents reviewed. The findings include: Review of the RAI Manual admission Version 3.0 dated 10/2019, showed the admission assessment can be no more than 14 days from the date of admission or reentry, whichever is later. Resident #1 was admitted to the facility on [DATE] with diagnoses including Chronic Atrial Fibrillation, Heart Failure, Type 2 Diabetes, and Chronic Kidney Disease. Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE], showed the assessment was not completed until 1/24/2022, 4 days late. During an interview on 6/28/2022 at 9:23 AM, the Special Project Nurse confirmed the admission assessment had been completed late, more than 14 days after the resident was admitted to the facility.
- Potential for harm · D2022-06-28 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to develop a baseline care plan to include the use of psychotropic medications for 1 resident (Resident #160) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy, Baseline Care Plan, revised 3/22/2022, showed .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .The baseline care plan will .Include the minimum healthcare information necessary to properly care for a resident .Initial goals based on admission orders .Physician orders .The admitting nurse .shall gather information from the admission .physician orders .Interventions shall be initiated that address the resident's current needs including .Any identified needs for supervision, behavioral interventions . Resident #160 was…
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 · D2022-06-28 · 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, medical record review, observation, and interview, the facility failed to follow a physician's order for wound treatment for 1 resident (Resident #10) of 4 residents reviewed for wounds. The findings include: Review of the facility policy titled, Wound Treatment Management, revised 3/24/2022, showed .Wound treatment will be provided in accordance to physician orders, including .type of dressing, and frequency of dressing change .The facility will follow specific physician orders for providing wound care . Resident #10 was admitted to the facility on [DATE] with diagnoses including Dementia, Peripheral Vascular Disease, Type 2 Diabetes Mellitus, Heart Failure, Impulse Disorders, Hypothyroidism, Adult Failure To Thrive, and Need For Assistance With Personal Care. Review of the Order Summary Report dated 6/4/2021, showed .House NP [Nurse Practitioner] Wound Care to eval [evaluate] and treat . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #10…
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 · D2022-06-28 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 follow a physician's order for an oral nutritional supplement for weight loss for 1 resident (Resident #37) of 3 residents reviewed for weight loss. The findings include: Review of the facility policy titled, Nutritional Management, dated 1/2/2020, showed .The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status .Interventions will .address the specific needs of the resident . Resident #37 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Anxiety Disorder, Repeated Falls, Symptoms and Signs Concerning Food and Fluid Intake, and Major Depressive Disorder. Review of Resident #37's facility documented weights showed on 5/5/2022 the resident was 86 pounds, and on 6/15/2022 was 84 pounds, indicating a weight loss of 2 pounds or 2.33 % (percent) loss. Review of a Certified Dietary Manager Progress…
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 · D2022-06-28 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, pharmacy recommendation review, and interview, the facility failed to act timely on a pharmacy recommendation for 1 resident (Resident #8) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Medication Regimen Review, dated 5/2022, showed .The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly .Recommendations are acted upon and documented by the facility staff . Review of the facility policy titled, Consultant Pharmacist Reports, dated 5/2022, showed .The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations, and are responded to in an appropriate and timely fashion .If the prescriber does not respond to…
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 · D2022-06-28 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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, pharmacy recommendation review, and interview, the facility failed to provide a gradual dose reduction per pharmacist recommendation for 1 resident (Resident #8) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Consultant Pharmacist Reports, dated 5/2022, showed .The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations, and are responded to in an appropriate and timely fashion .If the prescriber does not respond to recommendation directed to him/her [within 30 days], the Director of Nursing and/or the consultant pharmacist may contact the Medical Director . Resident #8 was admitted to the facility on [DATE] with diagnoses including Insomnia, Hypertension, Major Depressive…
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 · Fcited before2019-10-22 · 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 — an excerpt from the official record, may be distressing
Based on facility policy review, observation, and interview the facility failed to store cooking/serving utensils in a sanitary manner, failed to properly air dry 6 pans of approximately 15 pans observed, and failed to ensure expired foods were not available for resident use potentially affecting 64 of 65 residents. The findings include: Review of the facility's policy Storage of Clean Utensils and Pots and Pans, undated, revealed .This facility will ensure safe washing .and storage of cooking and serving utensils and pots and pans .All cooking and serving utensils and pots and pans will be air dried before storage in a clean .rack or storage shelf . Review of the facility's policy Refrigerators and Freezers, undated, revealed .This facility will .observe food expiration guidelines .Expiration dates on unopened food will be observed and use by dates indicated once food is opened .Culinary Services Manager will be responsible for ensuring food items .are not expired or past perish dates . Observation and interview with the [NAME] on 10/20/19 at 8:45 AM, in the kitchen, revealed 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 · Dcited before2019-10-22 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to accurately assess and document a Stage 2 pressure ulcer for 1 resident (#5) of 29 residents reviewed. The findings include: Review of CMS's RAI Version 3.0 Manual Chapter 3 Section M: Skin Conditions revealed .Enter the number of pressure ulcers that are currently present and whose deepest anatomical stage is Stage 2 . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Dementia, Psychosis, Major Depressive Disorder, and Adult Failure to Thrive. Medical record review of a Wound Care Progress Note dated 9/30/19 revealed .Left lateral foot, stage 2 . Medical record review of an Annual Minimum Data Set (MDS) dated [DATE] revealed the resident had zero Stage 2 pressure ulcers. Interview with the Wound Care Nurse Practitioner, on 10/22/19 at 8:25 AM, in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-10-22 · 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, review of facility documentation, and interview, the facility failed to revise a care plan for 1 resident (#50) of 29 residents reviewed. The findings include: Review of the facility policy Falls Management Program Guidelines, effective 12/1/18 revealed .[the facility] strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measure .the resident care plan should be updated to reflect, any new or change in interventions . Medical record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including Extrapyramidal and Movement Disorder, Paranoid Schizophrenia, Impulse Disorder, and History of Falling. Review of the Resident Event Report Worksheet dated 9/12/19, revealed Resident #50 had a fall without injury. Review of the Clinically at risk Observation dated 10/18/19 revealed .Fall 9/12/19 getting up out chair, no injuries, offer to assist to bed after meals . Medical record review of…
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 · D2019-10-22 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing 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 medical record review and interview, the facility failed to ensure vision services were provided for 1 resident (#23) of 16 residents reviewed for vision. The findings include: Medical record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Dementia, Cerebrovascular Accident (CVA), and Hemiplegia/ Hemiparesis. Medical record review of an Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. Medical record review of a physician's orders dated 10/20/17 revealed .Consults: Podiatry, Dental, Optometry, Ophthalmology . Medical record review revealed no documentation of vision services provided since Resident #23's admission date of 10/20/17. Interview with Resident #23 on 10/21/19 at 9:16 AM, in the resident's room, revealed she was unable to see without glasses and wanted to see an eye doctor. Further interview revealed she had requested to the facility to have her…
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 · D2019-10-22 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to ensure dental services were provided for 1 resident (#23) of 29 residents sampled. The findings include: Review of the facility policy Dental Services revised 12/16, revealed .Routine and emergency dental services are available to meet the resident's oral health services .Social Services representatives will assist residents with appointment, transportation arrangements . Medical record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Dementia, Cerebrovascular Accident (CVA), Hemiplegia/ Hemiparesis, and Dysphagia. Medical record review of an Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. Medical record review of a physician's order dated 10/20/17 revealed .Consults: Podiatry, Dental, Optometry, Ophthalmology . Medical record review revealed no documentation of dental…
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 · D2019-10-22 · 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, and interview, the facility failed to maintain an accurate medical record for 1 resident (#48) of 11 residents reviewed for medication administration. The findings include: Review of the facility policy Administering Medications revised 12/2012, revealed .Medications shall be administered in a safe and timely manner, and as prescribed .Medications must be administered within 1 hour of their prescribed time .the individual administering the medication will record in the resident's medical record .a. The date and time the medication was administered . Medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, Hypertension, and Major Depressive Disorder. Medical record review of Resident #48's October Medication Administration Record revealed the following medications were scheduled to be administered at 9:00 AM: * Allopurinol (medication to treat gout) 100 mg…
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 before2019-10-22 · 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, observation, and interview the facility failed to follow infection control guidelines during a wound observation for 1 resident (#5) of 3 wound observations. The findings include: Review of the facility's policy Infection Control Guidelines for All Nursing Procedures revised 8/2012, revealed .Purpose .To provide guidelines for general infection control while caring for residents .Employees must wash their hands .Before direct contact with residents . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Major Depressive Disorder, and Vascular Dementia with Behavioral Disturbance. Medical record review of a Wound Care Progress Note dated 10/22/19 revealed .Wound # [number] 2 .Deep tissue injury to left lateral foot measuring 1 x [by] 1.3 .Wound #3 .Healing stage 2 to the left lateral foot measuring 0.2 x 0.2 . Observation on 10/22/19 at 2:00 PM, in Resident #5's room, revealed the Regional Nurse entered 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.
“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
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE ENSIGN GROUP — 342 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 | 2 of 5 | 3.2 | -1.2 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 2 of 5 | 2.7 | -0.7 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
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 |
|---|---|---|---|---|
| ROCKY TOP HEALTHCARE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/18/2023 |
| ALBRECHTSEN, TYLER | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2024 |
| THATCHER, BRENT | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2024 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | — | since 12/18/2023 |
| SATO, AMI | Individual | CORPORATE OFFICER | — | since 09/09/2024 |
| HASEMEIER, ERIC | Individual | ADP OF THE SNF | — | since 05/01/2024 |
CMS files one row per role, so the 8 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 25% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TN
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 445297. 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.