Graceland Rehabilitation And Nursing Care Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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.

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.

42.8% 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 65 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 32.4% 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 34 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 52% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 240 beds and averages 168.2 residents a day — about 70% occupied, or roughly 72 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 3.47 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 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 3.10 hrs/resident/day on weekends vs 3.63 on weekdays — 15% thinner on weekends. RN hours go from 0.41 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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.

33 citations, most serious first. The 20 most serious are shown; the remaining 13 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-05-13 · 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, medical record review, facility investigation review, hospital record review, medical transport services record review, and interview, the facility failed to ensure residents remained free from accident hazards for 2 of 5 (Resident #415 and #515) sampled residents reviewed for accident hazards. The facility failed to ensure a vulnerable, non-verbal, cognitively impaired resident who required 2-person assistance with bed mobility and care, remained free from accident hazards as evidenced by failure to provide the required amount of assistance for safe repositioning and/or transfer, resulting in a significant injury and hospitalization for Resident #415. On 3/7/2025 at approximately 11:20 AM, Resident #415, a cognitively impaired Resident who was totally dependent on staff for mobility and required 2-person assistance with activities of daily living (ADLs) was receiving care from Certified Nursing Assistant (CNA) A and CNA B. CNA A and CNA B repositioned Resident #415 in the bed 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
• Immediate jeopardy · K2024-05-01 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, daily staffing records, medical record review, observation, and interview, the facility failed to ensure a sufficient number of licensed staff was available to provide care and services to all residents based on physician orders when there was no nurse to provide readmission assessments and services for 1 of 3 sampled residents (Resident #1) readmitted to the Crown Ventilation Unit on 4/4/2024 and failed to administer significant and other medications for 20 of 21 (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, and #24 ) sampled residents reviewed on the Crown Unit. The facility failed to ensure sufficient qualified nursing staff at all times to meet the residents ' needs safely and promote each resident's well-being when there were not a licensed nurse on the Crown Unit on 13 of 90 days (1/1/2024, 1/2/2024, 1/3/2024, 1/6/2024, 1/22/2024, 1/27/2024, and 1/28/2024 on the 11:00 to 7:00 AM shift, 1/6/2023 on the 3:00 PM to 11:00 PM shift,…

  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
• Immediate jeopardy · K2024-05-01 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to ensure residents were free from significant medication errors for 25 of 26 sample residents (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, #24, #35, #36, #38, #40, and #41) reviewed for medication administration. The facility's failure resulted in Immediate Jeopardy (IJ) when the residents' medications were not administered as prescribed for December 2023, January 2024, February 2024, March 2024, and April 2024, and had the likelihood to cause serious adverse outcomes. Immediate Jeopardy 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, or impairment, or death of a resident. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F760 on 4/23/2024 at 11:34 PM, in the Conference Room. The facility 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
• Immediate jeopardy · K2024-05-01 · tag F0835 — failed to run the facility competently — pattern
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  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 job description review, record review, medical record review, and interview, the facility Administration failed to administer the facility in a manner that provided oversight of the care being provided to residents, and ensure staff were sufficient in numbers and competent in their duties to provide care and services per physician orders and to meet the individualized needs of all residents. The facility Administration failed to have a system in place to ensure sufficient licensed nursing staff were available and with the knowledge and skills necessary to ensure residents were free from significant medication errors when medications were not administered as ordered by the physician for 25 of 26 sample residents (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, #24, #35, #36, #38, #40 and #41) reviewed who required medications and treatments. The medications not administered as ordered by the physician included anti-diabetics, anticoagulants,…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2024-05-01 · tag F0867 — failed to act on quality-improvement findings — pattern
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on job description review, facility document review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI /QA) committee failed to ensure a QAPI program that identified, implemented actions, and monitored serious issues affecting facility staffing, quality of care, prescribed care and services, and residents' rights for 20 of 21 (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23 and #24 ) sampled residents reviewed for prescribed medications, treatments, care and services during January 2024, February 2024, March 2024 and April 2024. (Resident #4) failed to receive appropriate monitoring after a fall on 3/29/2024 and underwent an emergency craniotomy (a type of brain surgery where a surgeon removes part of your skull to access your brain) on 3/30/2024. Residents #5 and #6) reviewed for the implementation of basic life support were not immediately provided Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) CPR. The facility failed to provide hair care in a manner that promoted a sense…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-05-01 · 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, user instruction manual review, job description review, medical record review, observation, and interview, the facility failed to ensure staff practices to prevent the potential spread of infection were maintained when multi-use blood glucometers were not cleaned and disinfected after/between resident testing to prevent cross-contamination of bloodborne pathogens for 5 of 9 sampled residents (Resident #9, #10, #11, #12, and #13) reviewed for blood glucose monitoring, when 1 of 3 nurses (Licensed Practical Nurse (LPN) A) failed to use appropriate Personal Protective Equipment (PPE) when providing care to Residents #9, #10, #11, #12, #17, and #18, and when staff failed to ensure reusable equipment was cleaned and disinfected when 2 of 2 staff members (Certified Nursing Assistant (CNA) N and CNA M) were observed during transferring Resident #4 with a mechanical lift. The facility's failure to ensure nursing staff properly disinfected the multi-use blood glucose meter that was used 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-05-01 · 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 policy review, job descriptions, medical record review, observation, and interview, the facility failed to provide supervision and monitoring for 1 of 5 (Resident #4) sampled residents reviewed for unwitnessed falls, failed to ensure the resident's right to be free from neglect when the facility failed to provide necessary goods and services and failed to treat residents in a manner that promoted a sense of self-worth, dignity and individuality for 11 of 11 sampled residents (Resident #7, #20, #28, #30, #37, #42, #44, #45, #46, #47 and #48) reviewed for daily hair care, and failed to ensure residents' vital signs were monitored [DATE], February 2024, [DATE] and [DATE], for 20 of 21 (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, and #24 ) sampled residents reviewed on the Crown Unit, a unit with residents that are dependent on ventilators and high acuity care requirements. Resident #4 experienced unwitnessed falls on [DATE], [DATE], [DATE], and on…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-05-01 · 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, observation, and interview, the facility failed to initiate and provide Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR - perform measures to assist the person with breathing and to stimulate a heart rate) for 2 of 3 sampled residents (Resident #5 and #6) reviewed in accordance with the professional standards of care related to basic life support for healthcare providers. Resident #5 who resided on the ventilation unit called the Crown Unit was found unresponsive and not breathing by Certified Nursing Assistant (CNA) B on [DATE] at 2:45 AM and was a full code (to receive CPR). Resident #6 who resided on the [NAME] Unit was found unresponsive on [DATE] at 3:50 AM by CNA H and was a full code. The facility failed to immediately initiate CPR according to the professional standard of practice for a healthcare provider and in accordance with the facility policy. The facility's failure to 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-05-01 · 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 facility policy, medical review and interview, the facility failed to follow physician orders to administer Tylenol (a medication used for moderate pain) for 1 of 6 (Resident #14) reviewed for quality of care. The findings include: 1. Review of the facility policy titled, Administering Medications, dated 2012, revealed .Medications shall be administered in a safe and timely manner, and as prescribed .Medications must be administered in accordance with the orders, including any required time frame .Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified . 2. Review of the medical record revealed Resident #14 was admitted on [DATE], with a readmission on [DATE], with diagnoses including Osteoarthrosis, Chronic Obstructive Pulmonary Disease, Transient Ischemic Attack, and Pain. Review of the quarterly MDS dated [DATE], revealed Resident #14 had a BMS score of 3, which indicated she was cognitively impaired with no behaviors identified and required physical…

  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
• Actual harm · Gcited before2024-05-01 · 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 policy review, medical record review, observation, and interview, the facility failed to prevent accidents/hazards, provide education and monitoring for 1 of 5 (Resident #4) sampled residents reviewed for falls, and failed to ensure a safe environment for 1 of 3 (Resident #3) residents sampled for elopement. The facility's failure to provide appropriate transfer with a mechanical lift resulted in actual harm when Resident #4 sustained a fall which resulted in a laceration to the forehead and required sutures. The findings include: 1. Review of the facility's policy titled, Assessing Falls and Their Causes, dated 2018, revealed .The purposes of this procedure are to provide guidelines for assisting a resident after a fall and to assist staff in identifying causes of the fall .Review the resident's care plan to assess for any special needs of the resident .Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly…

  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 · E2025-05-13 · 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, handled, prepared, and served under sanitary conditions, when stainless steel tables and metal storage racks were found with rust on the legs and black buildup around the base, the ice machine contained a dark brown, rust colored substance on the metal inside flap, food stored in the reach in cooler was unlabeled and undated, food items left on top of stainless steel tables was unattended and uncovered, dust was observed on top of a reach in cooler and around the edges of the ceiling vents, and when a substance with the appearance of rust was found around the edges of the ceiling vent and metal grates, when 9 stainless steel trays with food were found in the reach in cooler unlabeled and undated, the can opener contained thick black gummy buildup around the blade, when food items were found on top of a stainless steel table opened and undated, when dry ingredient storage bins that contained sugar and flour were unlabeled and undated with the lids soiled with thick yellow sticky debris,…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-05-13 · 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 proper infection control practices were followed when 2 of 2 staff members (Licensed Practical Nurse (LPN) DD and Housekeeping CC) failed to wear Personal Protective Equipment (PPE) for Transmission-Based (Isolation) Precautions and failed to properly perform hand hygiene after exiting Transmission-Based Precautions resident rooms. The facility failed to limit interactions with other residents when 1 of 4 (Resident #74) sampled residents reviewed for contact precautions was allowed to interact outside of his room with other residents. The findings include: 1. Review of the facility policy titled, Handwashing/Hand Hygiene, dated April 2010, revealed .This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Employees must wash…

  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 · D2025-05-13 · tag F0552 — isolated
  Ensure that residents are fully informed and understand their health status, care and treatments.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interviews, the facility failed to obtain consent for administration of psychotropic medications for 2 of 5 sampled residents (Resident #13 and #52) reviewed for unnecessary medications. The findings include: 1. Review of the facility policy titled, Psychotropic Medication Use, dated 7/2022, revealed .Residents will not receive medication that are not clinically indicated to treat a specific condition .A psychotropic medication is any mediation that affects brain activity associated with mental processes and behavior .Drugs in the following categories are considered psychotropic medications .Anti-psychotics .Anti-depressants .Anti-anxiety medications .Residents, families and/or the representative are involved in the medication management process .Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-13 · 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 policy review, medical record review, and interview, the facility failed to provide education and written information to resident and/or family representative to formulate an Advance Directive for 27 of 35 sampled residents (Resident #4, #22, #28, #29, #30, #37, #39, #42, #48, #66, #69, #75, #87, #91, #100, #102, #112, #119, #125, #129, #137, #139, #143, #146, #151, #265, and #465) reviewed for Advance Directives. The findings include: 1. Review of the facility policy titled, Advance Directives, dated 2001, revealed .The resident has the right to formulate an advance directive .Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family and/or his or her legal representative, about the existence of any written advance directives .The resident or representative is provided with written information concerning the right .to formulate an advance directive if he or she chooses to do so . 2. Review of the medical record revealed Resident #4 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-13 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  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 ensure as needed (PRN) psychotropic medications for 1 of 5 (Resident #52) sampled residents reviewed for unnecessary medications were limited to 14 days duration. The facility failed to obtain a physician's assessment or document rationale for continued use of the medication. The findings include: 1. Review of the facility policy titled, Psychotropic Medication Use, dated 7/2022, revealed .Residents will not receive medication that are not clinically indicated to treat a specific condition .A psychotropic medication is any mediation that affects brain activity associated with mental processes and behavior .Drugs in the following categories are considered psychotropic medications .Anti-psychotics .Anti-depressants .Anti-anxiety medications .Psychotropic medication management includes .indications for use .dose .duration .adequate monitoring for efficacy and adverse consequences .preventing, identifying 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-13 · 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 the facility policy review, medical record review, Incident Reporting System (IRS), and interview the facility failed to report sufficient information to describe the results of all investigations to the State Survey Agency within 5 working days of the incident for 1 of 2 (Resident #515) sampled residents reviewed for an injury of unknown origin. The findings include: 1. Review of the facility policy titled, Abuse Investigations, dated 4/2010, revealed .Policy Statement .All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management .Should an incident .of unknown source be reported, the Administrator .will appoint a member of management to investigate the alleged incident .The Administrator will provide a written report of the results of all .investigations and appropriate action taken to the state survey and certification agency .within five (5) working days of the reported incident . Review of the facility policy titled,…

  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 · D2025-05-13 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  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, record review, and interview, the facility failed to notify the resident's representative or family member of the intent to discharge for 1 of 3 (Resident #316) sampled residents reviewed for discharge. The findings include: 1. Review of the facility policy titled, Transfer or Discharge ., dated 8/2018, revealed .Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures .Notify the representative (sponsor) or family member . 2. Review of the medical record revealed Resident #316 was admitted to the facility on [DATE], with diagnoses including Pulmonary Embolism, Myocardial Infarction, and Acute Kidney Failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated Resident #316 was severely cognitively impaired. Review of the Nurse's Note dated 8/2/2023, revealed Resident discharged to…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-13 · 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, medical record review, and interview, the facility failed to follow physician's orders and obtain lab work for 2 of 5 (Resident #4 and #100) sampled residents reviewed for unnecessary medication use. The findings include: 1. Review of the facility policy titled, Laboratory Services and Reporting, dated 11/24/2024, revealed .The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state la .The facility is responsible for the timeliness of the service . 2. Review of the medical record revealed Resident #4 was re-admitted to the facility on [DATE], with diagnoses including Diabetes, Urinary Tract Infection, and Colostomy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 1, which indicated Resident #4 was severely cognitively impaired and received hypoglycemic medications. Review of the Care…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-13 · 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 medications were found unsecured and unattended in 1 of 78 (Resident #83) resident occupied rooms. The findings include: 1. Review of the facility policy titled, Storage of Medications, dated 4/2007, revealed .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . 2. Review of the medical record revealed Resident #83 was admitted to the facility on [DATE], with diagnoses including Diabetes, Alzheimer's Disease, Depression, and Hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated Resident #83 was severely cognitively impaired. During a random observation in the Resident's room on 5/5/2025 at 10:36 AM and at 11:22 AM, an unsecure and unattended medication cup with 8 pills was observed on the Resident's dresser.…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-29 · 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 policy review, observation, and interview, the facility failed to provide reasonable accommodations of needs for bathing when the water was not at the minimum temperature for hot water for 5 of 10 sampled residents (Resident #2, #7, #8, #9 and #10) reviewed for resident rights. The findings include: Review of the facility's undated policy titled Resident Rights revealed, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .self-determination . Review of the Rules of the Tennessee Health Facilities Commission dated July 2022, revealed .Water distribution systems shall be arranged to provide hot water at each hot water outlet at all times. Hot water at shower, bathing and hand washing facilities shall be between 105° [degrees] F [Fahrenheit] and 115°F . Review of the Resident Council Minutes dated October 8, 2024, revealed . MAINTENACE [MAINTENANCE] .WATER STILL NOT GETTING HOT . Review of .QAPI [Quality Assurance Process…

  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

“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.

Fines & penalties

$342,603 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $39,293 — penalty dated 2025-05-13
• $303,310 — penalty dated 2024-05-01
• Medicare payment denial — starting 2024-05-31 for 145 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

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

About 85% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.7M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TN