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Legacy Health And Rehab

811 Keylon Street, Manchester, TN 37355 · For profit - Limited Liability company · 72 certified beds · (931) 450-5150 Medicare & Medicaid certified

Call the home — (931) 450-5150 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Sep 2023
Insights

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

In its favor
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (35% 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 an abuse, neglect, or exploitation citation (F0600), cited Sep 2023
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
804 Keylon St · (931) 728-5522 · Call to confirm hours
Pharmacy
1277 McArthur St · (931) 728-1100 · Call to confirm hours
Grocery
801 S Spring St · (931) 728-3421 · Call to confirm hours
Park
168 Wilson St · (931) 728-0273 · 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 2 of 5
Long-stay residentspeople who live here 4 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 improved from 1 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
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 increased9.4%14.0%15.4%better
Long-stay residents who lose too much weight5.7%6.1%5.4%typical
Long-stay residents with a catheter left in their bladder2.6%0.7%0.9%worse
Long-stay residents with a urinary tract infection0.0%1.8%2.0%better
Long-stay residents with depressive symptoms19.9%13.8%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.0%3.4%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened17.4%17.2%16.1%typical
Long-stay residents on antianxiety or hypnotic medication48.5%31.7%18.9%worse
Long-stay residents given the seasonal flu vaccine96.1%94.5%95.3%typical
Long-stay residents with pressure ulcers2.8%5.0%4.7%better
Long-stay residents with worsening bladder/bowel control10.3%20.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table20.7%16.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.4%1.7%1.4%worse
Short-stay residents given the seasonal flu vaccine75.9%79.8%79.4%typical
Short-stay residents rehospitalized after admission10.8%22.6%22.6%better
Short-stay residents with an outpatient ER visit17.8%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.391.671.67worse
Long-stay outpatient ER visits per 1,000 resident days2.101.561.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

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

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

37.6% 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 37 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

37.6%U.S. median 51.5%
Got home and stayed home
11.6%U.S. median 10.7%
Went back to hospital
26.7%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 26.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 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 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% 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 SNF37.6%CMS range 23.6–55.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 8.5–16.810.7%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 discharge26.7%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 discharge36.7%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 discharge16.7%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 identified97.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.4%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 3.5–13.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.101.02Oct 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

0.43
RN hours/ resident / day
1.43
LPN hours/ resident / day
1.65
Aide hours/ resident / day
3.51
Total nurse hours/ resident / day
0.25
RN hoursweekends
35.4%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 72 beds and averages 50.9 residents a day — about 71% occupied, or roughly 21 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 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.65 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 3.06 hrs/resident/day on weekends vs 3.68 on weekdays — 17% thinner on weekends. RN hours go from 0.50 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below 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

8
deficiencies at the latest standard inspection (2025-06-25)
10
at the previous standard inspection (2024-04-10)

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.

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · Dcited before2025-06-25 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation and interview the facility failed to maintain a safe, clean, homelike environment for 4 residents (Residents #4, #6, #32, and #36) of 24 residents observed. The findings include: Review of the facility's policy titled, Homelike Environment, revised 2/2021, revealed .Residents are provided with a safe, clean .and homelike environment .The facility staff and management maximizes .the characteristics of the facility that reflect a personalized, homelike setting .The characteristics include .clean, sanitary and orderly environment . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, Congestive Heart Failure, and Acute Kidney Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-25 · 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 medical record review and interview, the facility failed to refer 2 residents (Residents #4 and #25), after the residents were diagnosed with a serious mental disorder, to the state-designated authority for a Level II Pre-admission Screening and Resident Review (PASARR) evaluation and determination of 10 residents reviewed for PASARR. The findings include: Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Diabetes, Congestive Heart Failure, and Depression. The diagnoses of Major Depressive Disorder, Insomnia, and Anxiety Disorder were added on 7/9/2024. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of a PASARR for Resident #4 submitted on 12/12/2023, revealed diagnoses .depression-mild or situational . The PASARR outcome was .Negative, No Level II Required . Review of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-25 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, and interviews, the facility failed to develop a person-centered care plan related to smoking for 1 resident (Resident #39) of 14 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2006, revealed .develops and implements .person-centered care plan for each resident .identifying problem areas .developing interventions .targeted .to the resident . Review of the facility's policy titled, Smoking Policy - Residents, revised 7/2017, revealed .any smoking privileges .concerns .shall be noted on the care plan . Review of the medical record revealed Resident #39 was admitted to facility on 8/14/2024 with diagnoses including Hemiplegia and Hemiparesis, Diabetes, and Nicotine Dependence. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #39 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which…

    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 · Dcited before2025-06-25 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to revise a comprehensive care plan for 1 Resident (Resident #34) of 14 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Care Planning - Interdisciplinary Team, dated 9/2013, revealed .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Dependence on Renal Dialysis, and Diabetes. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #34 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact and received dialysis services. Medical record review of the Comprehensive Care Plan for Resident #34 dated 3/26/2025, revealed .observe shunt site by palpating 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-25 · 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 facility policy review, medical record review, observations, and interviews, the facility failed to ensure a Physician's Order was obtained for oxygen therapy for 2 residents (Residents #4 and #255) of 6 residents reviewed for oxygen therapy. The findings include: Review of the facility's policy titled, Oxygen Administration, revised 10/ 2010, revealed .The purpose of this procedure is to provide guidelines for safe oxygen administration .Preparation .Verify that there is a physician's order for this procedure . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Diabetes, Chronic Obstructive Pulmonary Disease, and Acute Kidney Disease. Review of a facility document titled Report Sheet [report given to facility nurse from hospital nurse] for Resident #4 dated 1/27/2025, revealed .O2 [oxygen] 2 L/M [liters/minute] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 scored a 14 on the Brief Interview 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-25 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 review of the facility policy, review of kitchen equipment cleaning documentation, observation, and interview, the facility failed to ensure kitchen equipment was maintained in a clean and sanitary condition and failed to ensure dietary staff wore protective hair coverings during food preparation in the kitchen, which had the potential to affect 53 of 53 residents residing in the facility. The findings include: Review of the facility's policy titled, Sanitation, revised 10/2008, revealed .food service area shall be maintained in a clean and sanitary manner .equipment should be kept clean .all equipment .shall be washed to remove or completely loosen soils .using the manual or mechanical means necessary .for fixed equipment .removable components will be scraped to remove food particle accumulation .Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen .areas . Review of the facility's policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised 12/2017, revealed .Food and nutrition services employees…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-25 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on facility policy review, observation, and interviews the facility failed to ensure the outside dumpster area was maintained in a sanitary and orderly condition. The findings include: Review of the facility's policy, Food-Related Garbage and Refuse Disposal, revised 10/2017, revealed .outside dumpsters .will be kept .free of surrounding litter .storage areas will be kept clean at all times .shall not constitute a nuisance . During an observation of the outside dumpster area on 6/23/2025 at 10:08 AM, with the Dietary Manager (DM) revealed the area behind dumpster A and B had 2 broken light fixtures, 2 broken chairs, 1 broken office chair, 1 walker, 1 broken window air conditioner, and mop bucket on the ground. During an interview on 6/23/2025 at 10:11 AM, the DM stated the 2 broken light fixtures, 2 broken chairs, 1 broken office chair, 1 walker, 1 broken window air conditioner, and mop bucket on the ground were not disposed of properly and was unsure how long those items had been there. The DM confirmed the dumpster area had not been maintained in a sanitary condition.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation, and interview, the facility failed to provide a sanitary environment by failing to clean and store soiled items in a multi-resident bathroom for 1 Resident (Resident #4) of 10 residents observed. The findings include: Review of the facility's police titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, revised 6/2011, revealed .Rinse bedpan or urinal with cool water to remove feces and urine .Rinse with hot running water .Return bedpan or urinal to resident's bedside cabinet . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Diabetes, Chronic Obstructive Pulmonary Disease, and Acute Kidney Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an observation on 6/23/2025 at 11:37 AM, Resident #4's bathroom revealed 2…

    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 · F2024-04-10 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility's Payroll Based Journal (PBJ) report dated 10/1/2023-12/31/2023, daily nursing staff posting sheets, time clock punches, and interviews, the facility failed to provide the minimum requirement of 8 hours per day of Registered Nurse (RN) coverage on 20 days reviewed on the PBJ report and 12 days reviewed on 1/1/2024-4/10/2024 (not a PBJ report). The findings include: Review of the facility's PBJ dated 10/1/2023-12/31/2023 showed the following dates with no RN coverage: 10/7/2023 (Saturday), 10/14/2023 (Saturday), 10/15/2023 (Sunday), 10/29/2023 (Sunday), 11/4/2023 (Saturday), 11/5/2023 (Sunday), 11/12/2023 (Sunday), 11/18/2023 (Saturday), 11/26/2023 (Sunday), 12/2/2023 Saturday), 12/10/2023 (Sunday), 12/24/2023 (Sunday), and 12/31/2023 (Sunday). Review of the facility's daily staffing posting sheets, and time clock punches showed: 10/1/2023 (Sunday): 1.25 hours of RN coverage 10/21/2023 (Saturday): 3.02 hours of RN coverage 10/28/2023 (Saturday): 5.25 hours of RN coverage 11/11/2023 (Saturday): 2.83 hours of RN coverage 11/23/2023 (Monday): 1.48 hours…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-04-10 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on facility policy review, observation and interview the facility failed to post accurate staffing information to reflect daily staffing levels. The findings include: Review of the facility policy titled, Posting Direct Care Daily Staffing Numbers, revised 7/2016, showed .Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents During an observation on 4/8/2024 at 7:40 AM, of the daily nurse staffing showed the staffing information posted was the staff scheduled for 4/5/2024 and had not been updated to reflect the current staff in the facility on 4/8/2024. During an interview on 4/10/2024 at 2:035 PM, the Director of Nursing stated the Unit 1 Charge Nurse was responsible for posting the daily staffing sheet.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · Fcited before2024-04-10 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, observations, and interviews, the failed to ensure there was hot water was available for staff to wash/sanitize their hands in 1 of 2 kitchen hand washing sinks. The facility failed to maintain kitchen equipment in a sanitary manner and failed to ensure the kitchen floor was maintained in a sanitary manner, which had the potential to affect 52 of 52 residents. The findings include: Review of the facility policy titled, Sanitization, revised 10/2008, showed .All .kitchen areas .shall be kept clean .free from litter and rubbish .all equipment shall be kept clean .washed to remove soils .using mechanical means necessary . Observation and interview on 4/8/2024 at 8:35 AM, with the Dietary Manager (DM), at the kitchen handwashing station (located at the entry door), showed this surveyor attempted to wash her hands and the water remained cold. Further observation showed the water temperature did not change. The DM stated this sink had been transitioned from an eye wash station into a hand washing sink and the hot water had not been hooked up. Observation…

    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 · D2024-04-10 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of 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, observations, and interviews, the facility failed to ensure the call light was in reach for 1 resident (Resident #7) of 52 residents observed for call light accessibility. The findings include: Review of the facility's policy titled, Answering the Call Light, dated 3/2021, showed .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . Resident #7 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, Anxiety, and Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident was moderately cognitively impaired and required substantial/ maximum staff assistance with personal hygiene. Review of Resident #7's comprehensive care plan revised 4/2/2024, showed .Resident has need for extensive to total care related to .decreased functional 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-10 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 policy review, medical record review, and interview, the facility failed to provide a resident with information regarding a resident's right to formulate an advanced directive upon admission to the facility for 1 resident (Resident #3) of 18 residents reviewed for advanced directives. The findings include: Review of the facility policy titled Advance Directives, revised 12/2016, showed .Upon admission, the resident will be provided with written information .to formulate an advance directive . Resident #3 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Bipolar Type, Dementia, Psychotic Disorder with Hallucinations, Anxiety Disorder, and Hypertension. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severe cognitive impairment. Review of Resident #3's Advanced Directive Acknowledgement form showed the resident nor 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, review of a daily room cleaning check off sheet, observations, and interviews the facility failed to maintain a safe, clean, homelike environment for 6 residents (Residents #30, #25, #50, #3, #35, and #17) on 1 of 4 hallways observed. The findings include: Review of the facility's policy titled, Homelike Environment, revised 2/2021, showed .Residents are provided with a safe, clean .and homelike environment .The facility staff and management maximizes .the characteristics of the facility that reflect a personalized, homelike setting .The characteristics include .clean, sanitary .environment . Review of an Environmental Services/Housekeeping Daily Room Cleaning Check-Off sheet undated, showed .Toilet Cleaned .Floors Mopped . Resident #30 was admitted to the facility on [DATE] with diagnoses including Diabetes, Schizophrenia, Anxiety Disorder, and Depression. During an observation on 4/8/2024 at 8:05 AM, showed Resident #30's bathroom door frame had missing, chipped paint and there…

    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 · D2024-04-10 · 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 Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, observation, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 3 Residents (Resident #31, #20, and #14) of 10 Residents reviewed for anticoagulant use, and failed to accurately capture active diagnoses for 1 resident (Resident #14) of 18 resident reviewed for accurate MDS assessments. The findings include: Review of the RAI Version 3.0 Manual, Chapter 3, dated 10/2023, showed .Anticoagulant [medication used to prevent blood clotting] .Which may or may not require laboratory monitoring .should be coded on MDS .during the 7-day look-back period .code if taking and indication noted .if the item was used . Resident #31 was admitted to the facility on [DATE] with diagnoses including Pulmonary Embolism, Benign Prostatic Hyperplasia, Diverticulitis, and Depression. Review of Resident #31's current physician order dated…

    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 · Dcited before2024-04-10 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to develop a comprehensive care plan to include a colostomy (a surgical procedure which places a hole in the abdominal wall which allows waste to leave the body) for 1 resident (Resident #31) of 18 residents reviewed for care planning. The findings include: Review of the facility's policy titled, CARE PLAN POLICY, dated 12/2016, showed .A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed .for each resident .person centered care plan will .incorporate identified problem areas .reflect the residents expressed wishes regarding care and treatment goals .reflect currently recognized standards of practice for problem areas and conditions . Resident #31 was admitted to the facility on [DATE] with diagnoses including Pulmonary Embolism, Benign Prostatic Hyperplasia, Diverticulitis, Depression, and Dementia with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-10 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to revise a comprehensive care plan to reflect a new fall intervention for 1 resident (Resident #14) of 18 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, showed .care plans are revised as information about the residents and the residents' conditions change . Resident #14 was admitted to the facility on [DATE] with diagnoses including Abnormalities of Gait and Mobility, Muscle Weakness, and Need for Personal Care. Review of a post fall investigation dated 2/16/2024, showed Resident #14 was reaching for a drink and fell onto the floor from the bed. The immediate fall intervention was to remove the air mattress from the bed and place a regular mattress on the bed. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #14 had a Brief Interview for Mental Status (BIMS) score 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-10 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation, and interviews, the facility failed to ensure resident medications were secured in a locked location for 1 resident (Resident #30) of 2 residents reviewed for medication administration. The findings include: Review of the facility policy titled, Storage of Medications, revised 9/2020, showed .Drugs and biologicals used in the facility are stored in locked compartments .Only persons authorized to prepare and administer medications have access to locked medications .nursing staff is responsible for maintaining medication storage and preparation areas . Review of the facility policy titled, Administering Medications, revised 4/2019, showed .No medications are kept on top of the cart .the cart must be .inaccessible to residents or others passing by . Resident #30 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Schizophrenia, and Anxiety Disorder. During an observation on 4/9/2024 at 8:55 AM, Licensed Practical Nurse (LPN) #2 prepared…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-10 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview the facility failed to ensure appropriate notifications were conducted following a resident fall for 1 resident (Resident #454) of 4 residents reviewed for falls. The findings include: Review of the facility's policy titled, Assessing Falls and Their Causes, revised 3/2018, showed .Notify the following individuals when a resident falls .The resident's family .The Attending Physician .The Director of Nursing Services .The Nursing Supervisor on duty . Resident #454 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Cognitive Communication Deficit, Depression with Psychotic Features, Anxiety, Hypotension, and Urinary Tract Infection. Review of a Progress Note dated 1/27/2024 at 8:44 PM, showed Resident #454 was .ambulatory with a mostly steady gait, transfers herself numerous times and is at a high safety risk for all ADL's [activities of daily living] related to her severe cognitive decline…

    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 · D2023-09-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 a facility policy, facility investigation, medical record review, and interview, the facility failed to protect the resident's rights to be free from physical and mental abuse of 1 resident (Resident #2) of 5 reviewed for abuse and neglect. The findings included: Review of a facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program' revised April 2021, showed .residents have the right to be free from abuse .Abuse is defined as willful infliction of injury .all altercations, including those that may represent resident-to resident abuse, shall be investigated, and reported . Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Schizophrenia, Major Depressive Disorder, Generalized Anxiety Disorder, Type 2 Diabetes Mellitus, Pseudobulbar Affect and Parkinson's Disease. Review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 5 indicating severe…

    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 · Fcited before2021-10-27 · tag F0761 — failed to label and store drugs safely — widespread
    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 facility policy review, observation, and interview, the facility failed to monitor and document daily temperature checks for 2 medication refrigerators (400 hall and 600 hall) of 2 medication refrigerators sampled. The findings include: Review of the facility policy titled Refrigerators and Freezers dated December 2014, showed .Monthly tracking sheets for all refrigerators and freezers will be posted .Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily . Observation on 10/26/2021 at 3:10 PM, of the 600-hall medication room with the Director of Nursing (DON) showed the Daily Refrigerator Temperature Monitor log dated October had 15 (10/1/2021, 10/3/2021, 10/4/2021, 10/10/2021, 10/11/2021, 10/13/2021, 10/15/2021, 10/16/2021, 10/17/2021, 10/18/2021, 10/19/2021, 10/20/2021, 10/21/2021, 10/22/2021, and 10/24/2021) undocumented daily temperature checks. Observation on 10/26/2021 at 3:40 PM, of the 400-hall medication room with the Assistant Director of Nursing showed the Daily Refrigerator Temperature Monitor log…

    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 · E2021-10-27 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure 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 facility policy review, medical record review, observation, and interview the facility failed to administer medications timely to 3 residents (Residents #46, #30, and #36) observed for medication administration and maintain a medication error rate less than 5 percent as evidenced by 14 medication errors out of 29 medication administration opportunities resulting in a medication error rate of 44.8 percent. The findings include: Review of the facility policy, Administering Medications dated 4/2019 revealed .Medications are administered in accordance with prescriber orders, including any required time frames .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . Resident #46 was admitted to the facility on [DATE] with diagnoses including Diabetes, Chronic Obstructive Pulmonary Disease, Schizophrenia, and Anxiety Disorder. Review of the medical record for Resident #46 showed the monthly Physician Orders dated…

    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 · Dcited before2021-10-27 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to maintain a complete and accurate medical record for 1 resident (#17) of 24 residents reviewed for medical records. The findings include: Resident #17 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Cognitive Communication Deficit, Dysphasia, Dementia without Behavioral Disturbance, Paranoid Schizophrenia, and Essential Hypertension. Review of the Care Plan dated 6/30/2021 showed Resident #17 was a full code. Review of the medical record showed Resident #17 had a Tennessee Physician Orders for Scope of Treatment (POST) form with the resident's name, full code, full treatment choices, and section C, Artificially Administered Nutrition was not filled out. The document was signed by the Physician, the Resident, and a Licensed Practical Nurse and dated 6/23/2021. During an interview on 10/26/2021 at 2:06 PM, the Director of Nursing confirmed Resident #17's POST was incomplete.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-27 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on professional standards review, facility policy review, record review, observation, and interview, the facility failed to maintain infection control practices to ensure signage was posted on 1 resident's door (Resident #251) of 2 residents sampled for transmission-based precautions of 6 residents reviewed for infection control. The findings include: Review of the Centers for Disease Control Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes dated 9/10/2021, showed .unvaccinated residents who are new admissions .should be placed in a 14-day quarantine . Review of the facility policy titled Isolation - Categories of Transmission-Based Precautions, dated October 2018, showed .When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door . Resident #251 was admitted to the facility on [DATE] with diagnoses including Chronic Combined Systolic and Diastolic Heart Failure, Atherosclerotic Heart…

    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

“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
LEGACY HEALTH AND REHAB LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 09/18/2020
HOPKINS, HOLLYIndividualW-2 MANAGING EMPLOYEEsince 09/18/2020
DODGE, ROSEIndividualCORPORATE OFFICERsince 09/18/2020

CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$5.4M
Net patient revenuemost recent cost report
-9.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 71%Medicare 12%Other / private 17%

About 71% 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. 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

$317per resident / day
operating cost
$9,628per month
≈ monthly operating cost
$289per 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 445383. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-25, 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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