Legacy Park Health And Rehabilitation
7424 Middlebrook Pike, Knoxville, TN 37909 · For profit - Limited Liability company · 176 certified beds · (865) 690-3411 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $74,633 in federal fines (most recent 2025-02-27)
- 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 (1/5)
- nursing-staff turnover (64%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 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 | 2 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 held steady at 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.
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 | 6.4% | 14.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 12.2% | 6.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.7% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 14.5% | 13.8% | 6.5% | typical for the 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 | 2.4% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.1% | 17.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 29.4% | 31.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.2% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.7% | 5.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.3% | 20.0% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.3% | 16.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.8% | 1.7% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 76.5% | 79.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 24.8% | 22.6% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.9% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.44 | 1.67 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.66 | 1.56 | 1.80 | better |
‡ 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.
46.5% 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 101 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 55.0% 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 60 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.42 therapist hours per resident per day in 2026Q1 — more than 72% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 46.5%CMS range 36.5–57.1 | 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 | 10.2%CMS range 7.3–14.0 | 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 | 55.0% | 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 | 40.0% | 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 | 46.7% | 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 | 95.4% | 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 | 2.3% | 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 | 6.5%CMS range 3.3–11.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 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 176 beds and averages 125.8 residents a day — about 71% occupied, or roughly 50 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 3.33 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.95 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 2.88 hrs/resident/day on weekends vs 3.51 on weekdays — 18% thinner on weekends. RN hours go from 0.33 to 0.10 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 64% 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
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.
32 citations, most serious first. The 11 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · G2025-02-27 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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, hospice medical record review, and interview the facility failed to protect the residents right to be free from a significant medication error for 1 resident (Resident #7) of 3 sampled hospice respite residents. The facility's failure to prevent a significant medication error resulted in actual HARM for Resident #7. The facility's failure to prevent a significant medication error resulted in actual HARM for Resident #7 when the resident's order for Morphine Sulfate was transcribed incorrectly by nursing staff and Resident #7 was administered the medication on a scheduled basis instead of as needed, according to the physician order. On the fourth day of Resident #7's respite stay in the facility, she was semi-comatose, had constricted pupils, a weak and irregular pulse, slightly labored respirations of 12 with increased oxygen, and was hypotensive (low blood pressure), after she received the incorrect amount of Morphine for 4 days. The findings include:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-13 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, and interviews, the facility failed to protect the resident's right to dignity when an indwelling urinary catheter drainage bag was left uncovered and visible to the public for 1 resident (Resident #20) of 27 residents observed for dignity.The findings include: Review of the facility's policy titled, Resident Rights, revised 2/2021, revealed, .treat all residents with .dignity .Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Colon Cancer, Hypertension, and Dementia.Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 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 an indwelling urinary catheter.Review of an Order Summary report for Resident #20 dated 7/25/2025, revealed . [indwelling urinary…
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 before2025-08-13 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, facility policy review, medical record review, and interviews, the facility failed to ensure MDS assessments were accurate for 1 resident (Resident #116) of 27 residents reviewed for MDS assessments. The findings include: Review of the MDS 3.0 RAI Manual Verson 19.1, dated 10/2024, revealed .Health-related Quality of Life .residents covered by Level II PASRR [Pre-admission Screening and Resident Review] process may require certain care and services provided by the nursing home .Steps for Assessment .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness . Review of the facility's policy titled, Resident Assessment, revised 8/2018, revealed .It is the policy of this facility to ensure .assessments accurately reflect the resident's status . Review of the medical record revealed Resident #116 admitted to the facility on [DATE] with diagnoses including Bipolar Disorder and Major…
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 · D2025-08-13 · 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 facility policy review, medical record review, and interviews, the facility failed to develop a comprehensive care plan for 1 resident (Resident #116) of 27 residents reviewed for care planning. The findings include: Review of the facility's policy titled, Comprehensive Person-Centered Care Planning, revised 12/2023, revealed .the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's .mental and psychosocial needs .any specialized services as a result of PASARR [PASRR] [Pre-admission Screening and Resident Review] recommendation, and resident's goals and desired outcomes . Review of the medical record revealed Resident #116 admitted to the facility on [DATE] with diagnoses including Bipolar Disorder and Major Depressive Disorder. Review of a PASRR dated 10/15/2024, revealed Resident #116 had a PASRR Level II Outcome related to a serious mental illness. Review of a significant change…
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 · D2025-08-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, and interviews, the facility staff failed to perform appropriate hand hygiene when serving residents' meal trays for 9 residents (Resident #14, #91, #104. #107, #35, #119, #78, #108, and #87) of 1 of 3 dining areas observed for meal tray distribution. The findings include:Review of the facility's policy titled, Hand Hygiene, revised 4/2025, revealed .hand hygiene .most effective measures to prevent the spread of infection .during mealtimes the staff is to use proper hand hygiene .during tray pass .Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Dementia, and Hypertension. Review of the comprehensive care plan for Resident #14 revised 2/12/2025, revealed .ADL [Activities of Daily Living] Self Care Performance Deficit r/t [related to] limited mobility, weakness, dementia .assist resident on level needed to complete adls .Review of a quarterly Minimum Data Set (MDS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-27 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 ensure resident medical records were complete and accurate for 5 residents (Residents #2, #17, #18, #19, and #10) of 19 resident records reviewed. The findings include: Review of the facility's policy titled, Emptying a Urinary Collection Bag, dated 2001, revealed .The following information should be recorded in the resident's medical record .The amount of urine emptied from the drainage bag . Review of the facility's policy titled, Change in a Resident's Condition or Status, dated 2001, revealed .promptly notifies .his or her attending physician .changes in the resident's medical/mental condition and/or status .Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including .information prompted by the Interact SBAR [situation, background, assessment, recommendation] Communication Form . Review of the medical…
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 before2025-02-27 · 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, facility investigation review, and interview, the facility failed to ensure medications were administered according to Physician Orders for 1 resident (Resident #7) of 3 residents reviewed for hospice respite care. The findings include: Review of a facility policy titled, Medication and Treatment Orders, revised April 2019, revealed .Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medication in the state .Orders for medication should include .name and strength of the drug; dosage and frequency of administration; route of administration; clinical condition or symptoms for which the medication is prescribed .therapeutic medication monitoring . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], for 5 days of respite care with diagnoses including Normal Pressure Hydrocephalus (A rare condition that occurs when too much cerebrospinal fluid builds up in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-27 · 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, facility investigation review, and interview, the facility failed to ensure the Pharmacist identified an order for Morphine Concentrate was transcribed to Point Click Care (PCC) correctly on 1 resident (Resident #7's) of 3 sampled hospice respite residents ' Medication Administration Record (MAR) for accurate transcription of physician orders. The findings included: Review of the facility policy titled, Medication Regimen Review, effective 1/08/2024, revealed .A Medication Regimen Review (MRR) is a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication .review includes preventing, identifying, reporting and resolving medication-related problems .medication errors, or other irregularities, and collaborating with other members of the interdisciplinary team . Review of the medical record revealed Resident #7 was admitted to the facility on [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 · D2025-02-27 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, facility document review, Quality Assurance and Performance Improvement (QAPI) Plan review, and interview, the facility's QAPI committee failed to ensure an effective QAPI program that identified quality deficiencies, implemented performance improvement activities to address quality concerns, and performed a root cause analysis related to medication errors. The QAPI committee failed recognize, identify, develop and implement corrective systems to ensure appropriate care and safety by all disciplines involved in the medication transcription error. The QAPI committee failed to ensure facility wide education was conducted to ensure understanding of the transcription of hospice admission orders after a significant medication error was identified for 1 resident (Resident #7) related to the resident's Morphine orders. The QAPI committee failed to identify and implement an effective action plan to correct deficiencies when hospice orders were incorrectly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-31 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 document review, medical record review, and interviews, the facility failed to provide written information to the resident and/or resident representative concerning the right to formulate an advance directive for 22 residents (Resident #103, #156, #34, #5, #69, #45, #14, #102, #356, #67, #31, #47, #73, #99, #96, #8, #65, #3, #22, #12, #21,and #49) of 35 residents reviewed for advanced directives. The findings include: Review of the undated facility document titled, Advanced Directives revealed .On admission the Nurse Liaison inquires if the .resident has any advanced directives. If so, they request a copy and one is placed in the .medical chart .The Social Worker assists .resident .family with obtaining advance directives if requested .Copies are .placed in the .medical chart . Medical record review revealed Resident #103 was admitted to the facility on [DATE] with diagnoses including Hypertension, Anxiety Disorder, and Severe Protein-Calorie Malnutrition. Review of an admission Minimum Data…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-31 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, review of the Resident Assessment Instrument (RAI) Manual 3.0, medical record review, and interviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 residents (Resident #21 and #34) of 35 residents reviewed. The findings include: Review of the RAI Manual 3.0 dated 10/1/2023 revealed . 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 . Medical record review revealed Resident #21 was admitted to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 21 citations
- Potential for harm · D2024-05-31 · 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 medical record review and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASRR) after a new mental health diagnoses was identified to the state-designated authority for 1 resident (Resident #73) of 14 residents reviewed for PASRR. The findings include: Medical record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety, Panic Disorder and Adult Failure to Thrive. Review of a quarterly Minimum Data Set assessment dated [DATE], revealed Resident #73 scored a 3 on the Brief Interview for Mental Status Score (BIMS) which indicated the resident had severe cognitive impairment. The resident had a diagnoses of psychosis. Review of a PASRR for Resident #73, dated 5/1/2020, revealed .the following mental health conditions that are diagnosed .for this individual .Anxiety Disorder .Panic Disorder .If changes occur or additional information suggests .mental illness .rescreening should occur . Review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-31 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation and interviews, the facility failed to revise a comprehensive care plan with new interventions after falls for 2 residents (Residents #37 and #306) of 35 resident care plans reviewed. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, revealed .comprehensive, person-centered care plan .reflects currently recognized standards of practice for problem areas and conditions .interdisciplinary team reviews and updates the care plan .when the desired outcome is not met . Medical record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including Dementia, Pneumonia and Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #37 scored a 7 on the Brief Interview for Mental Status Score (BIMS) which indicated the resident had severe cognitive impairment and had 2 falls with no injury since last 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 · D2024-05-31 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 review of facility policy, observations, and interviews the facility failed to provide personal grooming for 1 resident (Resident #79) of 35 residents reviewed. The findings include: Review of the facility's policy titled Activities of Daily Living (ADL), Supporting, revised 3/2018, revealed .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living .Residents who are unable to carry out activities of daily living independently will receive .grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with .Hygiene (bathing, dressing, grooming .) . Medical record review revealed Resident #79 was admitted to the facility on [DATE] with diagnoses including Anemia, Candidiasis (yeast), and Bacterial Infection.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, safety data sheet review, medical record review, observations, and interviews the facility failed to ensure chemicals were secured for 1 resident (Resident #25) and failed to ensure medications were secured for 1 resident (Resident #27) of 35 residents observed. The findings include: Review of the facility policy titled Self-Administration of Medications, revised 2/2021 revealed .the interdisciplinary team (IDT) assesses each resident's cognition and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident .Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. Review of the facility's undated policy titled, Hygiene and Grooming Supplies, revealed .The resident's grooming needs are met while addressing . personal preferences and daily routine .all supplies are kept secured .if a resident has a 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 · D2024-05-31 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to document the fluid restriction amount and the amount consumed by the resident each shift on the Medication Administration Record (MAR) for 1 resident (Resident #31) of 1 resident reviewed for fluid restrictions. The findings include: Review of the facility's policy titled, Fluid Restriction, revised 5/10/2023, revealed .The fluid restriction amount .amount designated for each department .will be documented in the Physician order .and on the MAR .Fluid amount consumed .will be documented each shift .placed on the MAR . Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Edema, Acute Kidney Failure, and End Stage Renal Disease Requiring Renal Dialysis. Review of the Physician's Orders for Resident #31 dated 11/30/2023, revealed the resident was on a fluid restriction of 960 ml (milliliter)/day. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE],…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-31 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to develop a Dementia care plan for 2 residents (Resident #12 and #21) of 5 residents reviewed for Dementia Care. The findings include: Review of the facility policy titled, Dementia- Clinical Protocol, revised 11/2018, revealed .For the individual with confirmed dementia, the IDT [Interdisciplinary Team] will identify a resident-centered care plan to maximize remaining function and quality of life . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Dementia with Psychotic Disturbance, Alzheimer's Disease, and Vascular Disorder of the Intestine. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Active diagnoses for Resident #12 included Alzheimer's Disease and Non-Alzheimer's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-31 · 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 and interviews the facility failed to provide evaluation and rational for continued use of a PRN (as needed) antianxiety medication for 1 resident (Resident #16) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Psychotropic Medication Use, revised 7/2022, revealed .Residents will not receive medications that are not clinically indicated to treat a specific condition .A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior .Drugs in the following categories are considered psychotropic medications .Anti-anxiety medications .psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition document in the medical record .PRN orders for psychotropic medications are limited to 14 days . Medical record review revealed Resident #16 was admitted to the facility 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.
- Potential for harm · D2024-05-31 · 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 facility policy review, observations, and interviews the facility failed to label and date 1 medication on 1 medication cart of 3 medication carts observed, failed to assure medications were secure on 1 medication cart of 3 medication carts observed, failed to secure medications in 1 medication room of 2 medication rooms observed, and failed to remove expired supplies from 1 medication room of 2 medication rooms observed for medication storage. The findings include: Review of the facility's policy titled, Medication Labeling and Storage, revised 2/2023, revealed .Compartments .including .carts .containing medications .are locked when not in use and .carts used to transport such items are not left unattended if open or .potentially available to others .Controlled substance .subject to abuse are separately locked in permanently affixed compartments .Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-31 · 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, observation, and interview the facility failed to arrange dental care for 1 (Resident #34) of 3 residents reviewed for dental care. The findings include: Review of the facility policy titled, Dental Services revised 12/2016, revealed .Routine and 24-hour dental services are provided to our residents through .a contract agreement with licensed dentist that comes to the facility monthly .referral to the resident's personal dentist .referral to community dentist .referral to other health care organizations that provide dental care . Medical record review revealed Resident #34 was admitted to the facility on [DATE], with diagnoses including Anemia, Diabetes Mellitus, Hypothyroidism, and Generalized Muscle Weakness. Review of a Nurse Note written 3/6/2023, revealed Resident #34 had no upper teeth and was missing some lower teeth. Review of an annual Minimum Data Set (MDS) dated [DATE], revealed Resident #34 scored 15 on the Brief Interview for Mental Status…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-31 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on facility policy review, observation, and interview, the facility failed to ensure garbage and refuse were properly contained in 1 of 6 dumpsters. The findings include: Review of the facility's policy titled, Trash Disposal, dated 8/23/2023, revealed .dispose of trash appropriately and maintain the dumpster area for cleanliness and prevention of rodents .and that a dumpster plug is securely in place . Observation of the outside dumpster area on 5/28/2024 at 11:20 AM, revealed dumpster #6 did not have a dumpster plug. During an interview on 5/28/2024 at 11:25 AM, the Certified Dietary Manager (CDM) confirmed dumpster #6 did not have a dumpster plug.
- Potential for harm · D2024-05-31 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 offer informed consent prior to Pneumococcal vaccine administration for 2 residents (Resident #21 and Resident #38) of 5 residents reviewed for vaccinations. The findings include: Review of the facility's policy titled, Pneumococcal Vaccine (Series), revised 2/7/2023, revealed .Persons who reside in the [Name of Facility] .shall be given the Pneumococcal Immunization on admission unless medically contraindicated or the person has refused .Documented evidence of acceptance or declination against Pneumococcal for each person residing in the [Name of facility] shall be kept on file . Medical record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure, and History of Pulmonary Embolism. Review of the medical record for Resident #21 revealed the resident had not been provided with an informed consent for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-14 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 medical record review and interview, the facility failed to accurately transcribe a physician's order for 1 Resident (Resident #4) of 9 residents reviewed for physician's order. The findings included: Medical record review showed Resident #4 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Type 1 Diabetes without Complications, Long Term Insulin Use, Congestive Heart Failure, Peripheral Vascular Disease, History of Transient Ischemic Attack, and Hypertension. Review of the 5 Day Minimum Data Set (MDS) assessment dated [DATE], showed Resident #4 had a Brief Interview for Mental Status Score of 10 which indicated the resident had moderate cognitive impairment. Resident #4 was dependent upon renal dialysis twice weekly and required assistance of one or two persons with activities of daily living. Review of handwritten Physician orders dated 11/25/2023, showed Resident #4 was prescribed .Humulin R (short acting insulin) with House Sliding Scale AC and HS [before meals, 3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-01-29 · 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 Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to complete a timely annual Minimum Data Set (MDS) assessment for 1 resident (Resident #3) of 9 residents reviewed for MDS assessments. The findings include: Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .The Annual assessment .must be completed on an annual basis .AND within 92 days since the .previous .Quarterly . Resident #3 was admitted to the facility on [DATE] with diagnoses including Unspecified Psychosis, Major depressive Disorder, Unspecified Dementia, and Muscle Weakness. During review of the medical record and interview on 1/29/2020 at 3:17 PM, the MDS Nurse confirmed Resident #3 had a Quarterly MDS completed on 8/14/2019. No MDS assessments had been completed since that date. During an interview on 1/29/2020 at 3:45 PM, the MDS Nurse confirmed Resident #3's next annual MDS should have been completed on 11/14/2019. The resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-01-29 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 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 Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to complete a timely quarterly Minimum Data Set (MDS) assessment for 1 resident (Resident #4) of 9 residents reviewed for MDS assessments. The findings include: Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .The Quarterly assessment .must be completed at least every 92 days following the previous .assessment of any type . Resident #4 was admitted to the facility on [DATE] with diagnoses including Gout, Diastolic Congestive Heart Failure, Unspecified Dementia, and Muscle Weakness. During review of the medical record and interview on 1/29/2020 at 3:17 PM, the MDS Nurse confirmed Resident #4 had a quarterly MDS completed on 8/23/2019. No MDS assessments had been completed since that date. During an interview on 1/29/2020 at 3:45 PM, the MDS Nurse confirmed Resident #4's next quarterly MDS should have been completed on 11/23/2019. The resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-01-29 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 adequate supply of medications were available for 1 resident (Resident #131) of 8 residents reviewed for medication administration, resulting in staff borrowing pain medication from Resident #11 to administer to Resident #131. The findings include: Review of the facility policy titled, Acquisition of Medications for Residents, undated, showed .Pharmacy will provide medications for the residents .Reorder requests can be made by writing the drug needed on the provided refill request form, pulling the refill sticker from the pharmacy label and placing it on the provided refill request form, or calling the pharmacy . Resident #131 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Adult Failure to Thrive, and Peripheral Vascular Disease. Review of Resident #131's Physician Recapitulation Orders dated 1/1/2020-1/31/2020, revealed .NORCO 5-325 [also called Hydro/APAP-used to treat pain]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-01-29 · 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 medical record review, observation, and interview, the facility failed to provide proper positioning while seated in a wheelchair for 1 resident (Resident #53) of 28 sampled residents. The findings include: Resident #53 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Difficulty walking, Dementia, and Muscle Weakness. Review of the Care Plan dated 5/6/2019 revealed .Assist with all mobility needs prn [as needed] .Rehab to eval [evaluate] and treat as needed . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment and used a wheelchair for mobility. Observation of Resident #53 on 1/27/2020 at 11:08 AM, revealed the resident was propelling herself down the hallway in a wheelchair. The resident's feet were not touching the floor and there were no foot rests on the wheelchair. During an interview and observation of Resident #53 on 1/28/2020 at 2:00 PM, Licensed Practical Nurse (LPN) #5 confirmed Resident #53's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-01-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, review of manufacturer guidelines, record review, observation, and interview, the facility failed to use a mechanical lift safety for 1 (Resident #20) of 142 residents screened for accidents during the initial pool, which resulted in Resident #20 being left in a mechanical lift unattended. The findings include: Review of the facility policy titled, Lift Free Policy, dated 11/8/1994, showed .Effective 11/9/1994 it will be facility policy for all employees in the Nursing Department to use the mechanical lifts for lifting those residents identified .as requiring the use of a lift .the policy is instituted for the safety of our .residents . Review of the manufacturer guidelines for use of the mechanical lift dated 1/2014, showed .Before Approaching the patient .ensure that the battery pack supplied is fully charged before use . Resident #20 was admitted to the facility on [DATE] with diagnoses including Osteoarthritis, Type II Diabetes, and Difficulty Walking. Record 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.
- Potential for harm · D2020-01-29 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 record review, observation, interview, and staff skills and competency reviews, the facility failed to provide skills competencies for 1 (CNA #2) of 4 Certified Nursing Assistants (CNA) reviewed, which resulted in CNA #2 using a mechanical lift incorrectly for Resident #20. The findings include: Resident #20 was admitted to the facility on [DATE] with diagnoses including Osteoarthritis, Type II Diabetes, and Difficulty Walking. Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #20 was severely cognitively impaired and required extensive assistance of one staff member for bed mobility and transfers. Observation in the resident's room on 1/27/2020 at 11:18 AM, showed Resident #20 sitting on a pad in a mechanical lift suspended above the wheelchair. CNA #2 was attempting to lower the resident using the lift to the wheelchair. CNA #2 stated .it will not go on down. The battery must be dead .I'll have to get another battery to use . CNA #2 exited the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-01-29 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview the facility failed to ensure the medication error rate was less than 5 percent. There were 32 opportunities with 3 errors resulting in a 9% medication error rate. The errors involved 2 of 8 residents (Residents #389 and #112) in the sample. The findings include: Resident #389 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Anxiety Disorder, and Dementia. Review of Physician admission Orders dated 1/17/2020, showed .POLYETHYLENE GLYCOL 3350 [also called Miralax a medication to treat constipation] 17G [gram] .TAKE 34 GRAMS DAILY .FOR CONSTIPATION .SERTRALIN [Sertraline] [also called Zoloft a medication used to treat depression] 100 MG [milligram], take 1 ½ TAB PO [by mouth] DAILY FOR MOOD/DEPRESSION . During observation of the 200 hallway medication administration pass on 1/28/2020 at 8:05 AM, Licensed Practical Nurse (LPN) #1 prepared and administered the following medications to Resident #389: Miralax 17 gm and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-01-29 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure expired liquid protein supplements were not available for resident use in 1 medication cart of 4 medication carts observed. The findings include: During observation of the 200 hallway East side medication cart on [DATE] at 8:50 AM, two 30 ounce bottles of sugar free liquid protein, both bottles ½ full, with an expiration date of [DATE], was on the cart. During an interview on [DATE] at 8:54 AM, Licensed Practical Nurse (LPN) #1 confirmed both bottles of liquid protein expired on [DATE] and were available for resident use. During an interview on [DATE] at 2:18 PM, the Director of Nursing confirmed the facility had not removed 2 expired protein supplements from the 200 hallway East side medication cart.
- Potential for harm · D2020-01-29 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to obtain and maintain a hospice plan of care and hospice visit notes in the medical record for 1 of 3 residents (Resident #127) reviewed for hospice needs. The findings include: Resident #127 was admitted to the facility on [DATE] with diagnoses including Adult Failure to Thrive, and Unspecified protein-calorie Malnutrition. Review of a Physician's Order dated 12/4/2019, showed Resident #127 was admitted to hospice care. Review of the admission Minimum Data Set (MDS) dated [DATE], showed Resident #127 had severe cognitive impairment and received hospice services. Review of the medical record showed no documentation of a hospice care plan or hospice visit notes for Resident #127. During an interview on 1/29/2020 at 1:26 PM, Licensed Practical Nurse (LPN) #3 confirmed the hospice care plan and the visit notes for Resident #127 were not maintained on the resident's medical record. During an interview on 1/29/2020 at 2:23 PM, the Director of Nursing…
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
$74,633 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $74,633 — penalty dated 2025-02-27
- Medicare payment denial — starting 2025-03-29 for 16 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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.
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 445105. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-13, 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.