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Perry County Nursing Home

127 E Brooklyn Avenue, Linden, TN 37096 · For profit - Limited Liability company · 114 certified beds · (931) 589-2134 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Dec 20241 immediate-jeopardy citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (25% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
408 S Mill St
Pharmacy
119 S Mill St · (931) 589-2146 · Call to confirm hours
Grocery
100 W Main St · (931) 797-5522 · Call to confirm hours
Park
Old Highway 13 · (310) 372-1171 · Typically dawn to dusk
Place of worship

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 1 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased29.1%14.0%15.4%worse
Long-stay residents who lose too much weight9.0%6.1%5.4%worse
Long-stay residents with a catheter left in their bladder3.3%0.7%0.9%worse
Long-stay residents with a urinary tract infection0.7%1.8%2.0%better
Long-stay residents with depressive symptoms3.1%13.8%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained4.6%0.1%0.1%worse
Long-stay residents with falls causing major injury4.3%3.4%3.3%worse
Long-stay residents whose ability to walk worsened25.8%17.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication46.2%31.7%18.9%worse
Long-stay residents given the seasonal flu vaccine98.8%94.5%95.3%typical
Long-stay residents with pressure ulcers6.5%5.0%4.7%worse
Long-stay residents with worsening bladder/bowel control25.1%20.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table25.1%16.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.7%1.4%better
Short-stay residents given the seasonal flu vaccine41.4%79.8%79.4%worse
Short-stay residents rehospitalized after admission22.1%22.6%22.6%typical
Short-stay residents with an outpatient ER visit18.7%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.371.671.67worse
Long-stay outpatient ER visits per 1,000 resident days4.031.561.80worse

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.

42.0% 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 45 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

42.0%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
42.6%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 42.6% 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 61 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 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 40% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF42.0%CMS range 30.0–52.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 6.9–14.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge42.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge34.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge47.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified96.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 3.5–13.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.901.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.15
RN hours/ resident / day
1.12
LPN hours/ resident / day
2.21
Aide hours/ resident / day
3.48
Total nurse hours/ resident / day
0.11
RN hoursweekends
25.0%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 114 beds and averages 85.5 residents a day — about 75% occupied, or roughly 28 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 3.482 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.15 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.00 hrs/resident/day on weekends vs 3.68 on weekdays — 18% thinner on weekends. RN hours go from 0.17 to 0.11 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 25% is below 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

1
deficiencies at the latest standard inspection (2026-04-08)
10
at the previous standard inspection (2024-12-12)

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.

ABCDEFGHIJKL

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

22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.

  • Immediate jeopardy · J2023-08-01 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 policy review, review of the American Heart Association Provider Manual, medical record review, and interview, the facility failed to initiate and provide Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for 1 of 3 sampled residents (Resident #84) reviewed in accordance with the professional standards of care related to basic life support for healthcare providers. Resident #84 was found lying on the bed unresponsive, not breathing, and was a full code [if a person's heart stopped beating and /or they stopped breathing, all resuscitation procedures will be provided to keep them alive]. The facility failed to immediately initiate CPR according to the professional standard of practice. The facility's failure to immediately provide basic life support for Resident #84 resulted in Immediate Jeopardy (IJ). Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, facility list of resident tobacco users, medical record review, and interview, the facility failed to complete a smoking assessment for residents who use tobacco with each quarterly or comprehensive Minimum Data Set (MDS) assessment to ensure safe smoking for 4 of 5 (Resident # 16, #25, #37, and #65) residents sampled for smoking assessments. The findings include: 1. Review of the facility policy titled, Resident Smoking, dated 10/24/2022, revealed .It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking.All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process.Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all.A safe smoking assessment will be completed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-12 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, and interview, the facility failed to ensure food was properly stored under sanitary conditions. In the kitchen, the vent hood was observed soiled, and 3 of 3 (West Hall, North Hall, and East Hall) nutrition refrigerators contained dead pests, opened, undated, unlabeled, and expired food items, and no thermometer. The findings include: 1. Observation in the kitchen on 12/9/2024 at 8:49 AM, revealed the following: a. a vent hood over the kitchen stove with dust and grease buildup. 2. Observation in the [NAME] hall nourishment refrigerator on 12/10/24 at 3:52 PM, revealed the following: a. dead gnats (tiny black pests) on the bottom of the refrigerator. b. 1 opened, undated bottle of ketchup. c. 1 opened, undated and unlabeled bottle ranch dressing. d. 1 undated and unlabeled red bowl with unidentified food item. e. 1 undated and unlabeled breakfast sandwich. f. 1 undated and unlabeled frozen dinner. g. 1 undated and unlabeled divided plate with food items. h. 1 expired Jell-O cup (gelatin cup) dated 9/30/2024. i. 1 opened, undated, unlabeled, expired pack 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-12 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 1 (Certified Nursing Assistant (CNA) C) staff members was observed administering perineal care without the use of Personal Protective Equipment (PPE), when 1 of 1 (CNA B) staff members walked down the hall adorned in PPE, and when 1 of 1 (Wound Nurse) staff members failed to use hand hygiene during wound care. The findings include: 1. The facility's policy titled, Hand Hygiene, dated 11/12/2024, revealed .Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub .The use of gloves does not replace hand washing. Wash hands after removing gloves . 2. Review of the medical record revealed…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-12 · tag F0572 — isolated
    Give residents a notice of rights, rules, services and charges.
    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 policy review, review of meeting minutes, medical record review, and interview, the facility failed to ensure resident rights were reviewed during resident council meeting for 5 of 10 residents (Resident #10, #36, #38, #41, and #50) in attendance during resident council meeting. The findings include: 1. Review of the facility policy titled, Resident Rights, dated 9/2024, revealed The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility . 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Anemia, Anxiety and Kidney Failure. Review of the MDS dated quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #10 was cognitively intact. 3. Review of the medical record revealed 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-12 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to report an allegation of resident to resident abuse for 2 of 2 sampled residents (Resident #18 and #32) reviewed for abuse. The findings include: 1. Review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated 1/20/2023, revealed .Each resident has the right to be free from abuse .Response and Reporting of Abuse .When abuse .is suspected .Contact the State Agency and the local Ombudsman office to report the alleged abuse .The Administrator should follow up with the government agencies .to confirm the report was received, and to report the results of the investigation when final . 2. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses including Alcoholic Cirrhosis, Depression, and Paranoid Schizophrenia. Review of the Care Plan dated 9/19/2023, revealed .potential for behavior problem r/t [related to] paranoid schizophrenia, hepatic encephalopathy,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-12 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to investigate an allegation of resident to resident abuse for 2 of 2 sampled residents (Resident #18 and #32) reviewed for abuse. The findings include: 1. Review of the facility policy titled, Abuse, Neglect, and Exploitation, dated 1/20/2023, revealed When suspicions of abuse .or reports of abuse .an investigation is immediately warranted .Components of an investigation may include .if the residents response is incongruent .interview the resident's family .gather how .the resident would react to the incident .Obtain witness statements, according to appropriate policies. All statements should be signed and dated .all alleged violations involving abuse .are reported immediately, but not more that 2 hours after the allegation is made .to the administrator of the facility and to other official (including the State Survey Agency) .Have evidence that all alleged violations are thoroughly investigated . 2. Review of the medical record…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 Center's for Medicare Services (CMS) Pressure Ulcer/Injury Coding Stages, policy review, medical record review, and interview, the facility failed to ensure staff failed to correctly identify and stage a pressure ulcer and failed to notify patient representative for changes for 1 of 3 (Resident #53) sampled residents reviewed for pressure ulcers. The findings include: 1. The CMS undated pocket guide for Pressure Ulcer / Injury Coding Stages, revealed .Stage 3 .Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough (dead tissue on the surface of the wound bed that prevents healing) may be present but does not obscure (prevent) the depth (deepness of the wound) of tissue loss .Pressure ulcer known but not stageable due to coverage of wound bed by slough and/or eschar . Unstageable pressure ulcers due to slough and/or eschar .Percentage of slough in a wound refers to the proportion of the wound bed that is covered by dead tissue [slough] .while 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, medical record review, observation, and interview, the facility failed to ensure residents were free from accident hazards when sharps and hazardous personal items were found in 2 of 54 (Resident #19 and #56) resident occupied rooms and when in 1 of 3 (East Hall Shower Room) Shower Rooms was found unsecured and unattended with sharps and hazardous items. The findings include: 1. Review of the facility's policy titled, Care and Storage of Personal Care Items, dated 12/2024, revealed It is the policy of the facility to properly stored resident personal care items such as deodorant, shampoo, mouthwash, safety razors, fingernail clippers in a safe area to ensure safety .Resident mouthwash should be stored in a closed cabinet inside the resident room .Shampoo and bathing chemical should always be stored in a closed cabinet .If razors are used, discard in the sharps container or store in a locked cabinet . 2. Review of the medical record revealed Resident #19 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-12 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 care and services for residents with a percutaneous endoscopic gastrostomy (PEG) tube (tube inserted into the stomach to administer medications, supplements and liquid food) when staff failed to ensure the enteral feedings and the flush solutions were properly labeled for 2 of 2 (Resident #51 and #59) sampled residents reviewed for enteral feedings. The findings include: 1. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Dementia, Dysphagia, and Anorexia. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed no Brief Interview for Mental Status (BIMS) score but documented that her cognitive skills for daily decision making were severely impaired. Resident #51 was dependent on staff for all care and was coded for a Feeding Tube. Review of the annual MDS dated [DATE], revealed no Brief Interview for Mental Status (BIMS) score was assessed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to follow physician orders for the use of oxygen and failed to ensure oxygen concentrators were clean for 2 of 2 (Resident #29 and #40) sampled residents reviewed for oxygen use. The findings include: 1. Review of the facility's policy Oxygen Administration dated 10/14/2024, revealed .Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air .with the intent of treating or preventing the symptoms and manifestations of hypoxia .Hypoxia means decreased perfusion of oxygen to the tissues .Oxygen is administered under orders of a physician .Staff shall document the initial ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy .Cleaning and care of equipment shall be in accordance with facility's policies for such equipment . 2. Medical record review revealed Resident #29 was admitted to the facility on [DATE], with diagnoses including…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · Dcited before2024-12-12 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 3 (Licensed Practical Nurses (LPN) F) nurses observed during medication administration left medications unsecured and unattended and during a random observation medications were found unsecured and unattended in 1 of 54 (Resident #56) resident occupied bathrooms. The findings include: 1. Review of the facility policy titled, Medication Storage reviewed and revised on 10/2024, revealed .It is the policy of this facility to ensure all medications housed on our premises will be stored .according to manufacturer's recommendations and sufficient to ensure proper .segregation and security .all drugs and biologicals will be stored in locked compartments .medication carts, cabinets, drawers .medication rooms .During a medication pass, medications must be under direct observation of the person administering medications or locked in the medication storage area/cart…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-01 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when the kitchen equipment and environment was not maintained in sanitary conditions, and when opened and undated food was observed in the cooler and refrigerator. The facility served 77 resident lunch meal trays on 7/24/2023 and 78 resident dinner meal trays on 7/25/2023. The findings include: 1. Review of the facility's policy titled, Sanitization Inspection, dated 2023, revealed .conduct inspections to ensure food areas are clean, sanitary, and in compliance with applicable .regulations .food service areas shall be kept clean, sanitary, free from litter, rubbish, and protected from rodents, roaches, flies and other insects .The department shall establish a sanitation program for food services .dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations .not limited to .dry storage, freezer, refrigerator .shall develop and provide food service personnel…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-01 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, observation, and interview, the facility failed to maintain or enhance the resident's dignity and respect during dining when 2 of 20 staff members (Certified Nursing Assistant (CNA) #2 and #5) stood to assist Resident #36 with meals. The findings include: 1. Review of the facility's policy titled, Promoting/Maintaining Resident Dignity During Mealtimes, dated 3/21/2023, revealed .It is the practice of this facility to treat each resident with respect and dignity .in a manner and .environment that maintains or enhances his or her quality of life .protecting the rights of each resident .All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes .All staff will be seated .while feeding a resident . 2. Observation in the resident's room on 7/24/2023 at 11:44 AM, revealed CNA #5 stood over Resident #36 while she assisted her with her meal. 3. Observation on 7/25/2023 at 4:15 PM, revealed CNA #2 stood over Resident #36 while she assisted her with her meal. 4. During an interview on 7/28/2023 at…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-01 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, facility investigation review, medical record review, and interview, the facility failed to report an allegation of abuse for 2 of 2 sampled residents (Resident #31 and #45) reviewed for abuse. The findings include: 1. Review of the facility policy titled, Abuse, Neglect, and Exploitation, dated 1/20/2023, revealed .Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Response and Reporting of Abuse .When abuse .is suspected .Contact the State Agency and the local Ombudsman office to report the alleged abuse .The Administrator should follow up with the government agencies .to confirm the report was received, and to report the results of the investigation when final . 2. Review of the facility investigation dated 7/19/2023, revealed a physical altercation occurred on the smoking porch between Resident #31 and #45. The altercation was witnessed by Resident #69 and Certified Nursing Assistant (CNA #6). Facility staff immediately…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-01 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual v 1.17.1, October 2019, medical record review, and interview, the facility failed to accurately assess residents for medications, diagnoses, bowel incontinence, and hospice for 4 of 20 (Resident #43, #48, #58, and #74) sampled residents reviewed for accuracy of Minimum Data Set (MDS) assessments. The findings include: 1. Review of the Minimum Data Set, 3.0 RAI Manual v 1.17.1, dated October 2019, page 1-7 revealed .Federal regulations . require that (1) the assessment accurately reflects the resident's status . 2. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses of Dementia, Hypertension, Altered Mental Status, Benign Prostatic Hyperplasia. Review of the quarterly MDS dated [DATE], documented Resident #43 received an antipsychotic medication on 7 of 7 days and did not receive opioid medication. Review of the Medication Record dated July 2023, revealed Resident #43…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-01 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Pre-admission Screening and Resident Review (PASRR) User Guide for Medicaid Certified Nursing Facilities, policy review, medical record review, and interview, the facility failed to resubmit a PASRR after the resident had the addition of a new mental health diagnosis for 2 of 2 (Resident #4 and #45) sampled residents reviewed for PASRR. The findings include: 1. Review of the PASRR User Guide for Medicaid Certified Nursing Facilities, dated 12/11/2018, revealed .Resident Review-you will submit the Level I if the individual has .a significant change in status .Potential Outcomes--PASRR Level II . Review of the Resident Assessment-Coordination with PASARR Program, policy dated 3/31/2023, revealed .Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to a mental health or intellectual disability authority for a level II resident review . 2. Review of the medical record revealed Resident #4 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-01 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to revise care plans for 3 of 20 (Resident #45, #74 and #84) sampled residents reviewed for care planning. The findings include: 1. Review of the facility's policy titled, Comprehensive Care Plans, dated 3/31/2023, revealed .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment .measurable objectives and timeframes .objectives will be utilized to monitor the resident's progress . 2. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE], with diagnoses of Anxiety Disorder, Depression, Schizophrenia, Personality Disorder, Major Depressive Disorder, Schizoaffective Disorder, Bipolar Type, and Psychoactive Substance Abuse. The annual MDS dated [DATE], revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #45 was cognitively intact,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-01 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 policy review, wound protocol, medical record review, observation, and interview, the facility failed to follow physician's orders for wound/skin care as prescribed for 2 of 20 (Resident #48 and #84) sampled residents. The findings include: 1. Review of the undated facility policy titled, PHYSICAN SERVICES, revealed, .All orders will be followed as written . Review of the undated facility protocol titled, SKIN WOUND MANAGEMENT PROTOCOLS, revealed .SKIN TEAR/ABRASIONS .LACERATIONS .Change dressing every 3-5 days and prn [as needed] . 2. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Viral Hepatitis, Schizoaffective Disorder, Bipolar Disorder, and Head Injury. Review of the Physician's Order dated 6/29/2023, revealed WOUND CARE PER [Named facility] PROTOCOL TO EVAL [Evaluate] & [and] TX [treat] as indicated . Review of the WOUND CARE PROGRESS NOTES dated 7/18/2023, revealed Resident noted in lobby [symbol for with] L [left]…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 policy review, facility SKIN/WOUND MANAGEMENT protocol review, medical record review, observation, and interview the facility failed to provide pressure ulcer treatments for 1 of 2 residents (Resident #4) reviewed for pressure ulcers. The findings include: 1. Review of the undated facility policy titled, PHYSICAN SERVICES, revealed, .All orders will be followed as written . Review of the undated facility protocol titled, SKIN/WOUND MANAGEMENT PROTOCOLS, revealed .WOUNDS WITH ESCHAR .TREATMENT .Follow .physician recommendations . 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses of Schizoaffective Disorder, Insomnia, Depression, and Diabetic Mellitus. Review of the .Wound Assessment Form dated 6/15/2023, revealed .admitted with yes .pressure SDTI [suspected deep tissue injury] .R [right] heel .3.5 [centimeters (cm)] [length (l)] .2.5 [width (w)] .utd [unable to determine] [depth (d)] .purple boggy tissue .Necrotic [dead tissue] 100% [percent]…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to provide the necessary respiratory care and services when the facility failed to obtain a Physician's order for oxygen, and the oxygen tubing was lying on the floor for 1 of 1 sampled resident (Resident #74) reviewed for oxygen therapy. The findings include: 1. Review of the facility's policy titled .Oxygen Administration, dated 4/2018, revealed Oxygen is administrated to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans .Oxygen is administered under orders of a physician .Cleaning and care of equipment of equipment shall be in accordance with facility policies for such equipment . 2. Review of the medical record revealed Resident #74 was admitted to the facility on [DATE], with diagnoses of Anemia, Hypothyroidism, Dysphagia, Adult Failure to Thrive, Insomnia, and Arthritis. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-01 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when externals and internals (Internal use only and External use only) were stored together in 1 of 6 (West Medication Room) medication storage areas. The findings include: 1. Review of the facility's policy titled .Medication Storage dated 6/12, revealed .Injectables, eye/ear medications, suppositories--are considered internal medications and are stored separately from external medication .All medications with routes other than PO [by mouth] --must be stored in separate compartments in the medication cart, medication room cabinets, or refrigerator . 2. Observation in the [NAME] Medication Room on 7/26/2023 at 2:43 PM, revealed the upper cabinet had 4 saline enemas (for constipation) and a small plastic tray containing 1 bottle of Biotene moisturizing spray (for dry mouth), 1 bottle Biotene oral rinse (for dry mouth), a tube of toothpaste, and 1 can of aerosol spray deodorant. During an interview on 7/26/2023 at 5:36 PM, the Director of Nursing (DON) 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
HINSON, BRENTIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTORNO PERCENTAGE PROVIDEDsince 11/10/2010

CMS files one row per role, so the 3 rows in the source record cover these 1 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$8.1M
Net patient revenuemost recent cost report
-4.2%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 78%Medicare 5%Other / private 17%

About 78% 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.

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

$283per resident / day
operating cost
$8,603per month
≈ monthly operating cost
$271per day
avg. revenue, all payers

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

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 445503. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-08, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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