Cedar Creek Post Acute

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.

46.4% 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 57 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 53.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 39 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 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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.

Staffing

How full it usually is: this home is certified for 106 beds and averages 91.9 residents a day — about 87% occupied, or roughly 14 beds typically open. It runs fairly full. 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 4.95 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.00 is at or above 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 4.92 hrs/resident/day on weekends vs 4.97 on weekdays — 1% thinner on weekends. RN hours go from 0.40 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 67% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

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

Inspection deficiencies

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

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

32 citations, most serious first. The 21 most serious are shown; the remaining 11 are one tap away and print in full.

• Immediate jeopardy · Kcited before2024-04-11 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  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 facility policy review, www.hopkinsmedicine.org/health, Police Incident Report dated [DATE] review, facility investigation review, medical record review and interviews, the facility failed to ensure residents were free from abuse/sexual for 6 of 9 (Residents #3, #7, #9, #11, #14, and #15) sampled residents reviewed for abuse/neglect. On [DATE] during group activities Resident #11, who had a BIMS of 12, approached Resident #15, who had a BIMS of 4, began to rub across her shoulders and back, and then tried to kiss her. Resident #15 told Resident #11 to stop and pushed him away. Resident #11 then put some money on the table in front of Resident #15 and pushed it towards her while saying, If this isn't enough, let me know. On [DATE] Resident #11 approached Resident #15 during activities and pulled up his shirt and began rubbing his nipples. Resident #15 pushed him away from her. Resident #11 returned to his table and within a few minutes, stood up, pulled his pants down, and pointed to his penis saying, If…

  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 · Kcited before2024-04-11 · 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 facility policy review, (Named Glucometer- a device used to check blood sugar levels with the use of a blood sample) User's Guide review, Guidelines for General Use of (Named germicidal cloth) wipes used by the facility review, DME (Durable Medical Equipment) supplier recommendation letter review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when a multi-use blood glucose meter was not cleaned and disinfected with facility required cleansing wipes to prevent cross-contamination of bloodborne pathogens for 2 of 11 (Residents #17 and Resident #18) sampled residents reviewed for blood glucose monitoring. Observations on 4/2/2024 revealed Licensed Practical Nurse (LPN) P failed to clean and disinfect the multi-use blood glucose meter before and after use on each resident in accordance with recommendations and facility policy, failed to perform hand hygiene, and failed to don gloves when performing…

  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 · J2024-04-11 · 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 policy review, medical record review, and interview, the facility failed to notify and consult the Physician/Nurse Practitioner (NP) of a change in condition related to falls 1 of 6 (Resident #7) sampled residents reviewed for change in condition. On [DATE], Resident #7 had an unwitnessed fall and was found on the floor with his head under the bed. Resident #7 hit his head while being placed back in bed by staff. The Physician/NP was not notified of Resident #7's unwitnessed fall on [DATE], and on [DATE], Resident #7 experienced a change in mental status. The NP was notified on [DATE] (1 day after the change in mental status and 4 days after the unwitnessed fall) of Resident #7's change in condition and again, was not notified of the unwitnessed fall the resident sustained on [DATE]. The facility's failure to immediately notify the Physician/NP of Resident #7's fall with injury resulted in Immediate Jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements 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 Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2020-03-10 · 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 facility policy review, medical record review, facility documentation review, and interview the facility failed to ensure 1 of 38 residents (Resident #33) was free from abuse placing the resident in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) when Resident #33 sustained a left humerus (long bone that extends from the shoulder to the elbow) fracture during an attempted transfer, without a mechanical lift, on 10/22/2019. The facility failed to ensure Resident #33 was free from Psychosocial harm as evidenced by Resident #33 had increased anxiousness, cried when she talked about the incident that occurred on 10/22/2019, was fearful of Certified Nursing Assistant (CNA) #1, and received psychosocial therapy and medication changes. The Administrator, Director of Nursing (DON), and Regional Nurse Consultants were notified of the Immediate…

  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 · J2020-03-10 · 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 facility policy review, medical record review, and interview the facility failed to report an abuse allegation to the State Survey Agency for 1 of 38 residents (Resident #33) reviewed or abuse. The Administrator, Director of Nursing (DON), and Regional Nurse Consultants were notified of the Immediate Jeopardy (IJ) on 3/3/2020 at 7:31 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-609. The facility was cited at F-609 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 10/2/2019 through 3/5/2020. An Immediate Action Removal Plan, which removed the immediacy of the jeopardy was received on 3/6/2020 at 2:55 PM. The corrective actions were validated onsite by the surveyors on 3/6/2020. The facility's noncompliance at F-609 continues a a scope and severity of, D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings…

  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 · J2020-03-10 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to investigate an abuse allegation for 1 of 38 residents (Resident #33) reviewed for abuse. The facility was cited Immediate Jeopardy at F-610. The facility was cited at F-610 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 10/2/2019 through 3/5/2020. An Immediate Action Removal Plan, which removed the immediacy of the jeopardy was received on 3/6/2020 at 2:55 PM. The corrective actions were validated onsite by the surveyors on 3/6/2020. The facility's noncompliance at F-610 continues a a scope and severity of, D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy, Abuse Prohibition Plan, revised 5/2019, showed, .The policy of this facility is that reports of abuse, neglect, exploitation, misappropriation of resident's…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2020-03-10 · 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 and implement a person centered care plan with interventions related to blood sugar monitoring and tube feeding residual to prevent hypoglycemia for 1 of 38 residents (Resident #77) reviewed for implementation of care plans placing Resident #77 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) when Resident #77 became unresponsive, hypoglycemic, and required emergent hospitalization. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 3/5/2020 at 3:50 PM in the Administrators office. The facility was cited Immediate Jeopardy at F-656. The facility was cited F-656 at a scope and severity Level of J. The Immediate Jeopardy was effective from 10/2/2019 through 3/5/2020. The Immediate Jeopardy was removed onsite…

  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
• Immediate jeopardy · J2020-03-10 · 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 facility policy review, medical record review, and interview the facility failed to ensure a resident's Advance Directive preference was accurately reflected in the medical record for 2 of 91 residents (Resident #49 and #6) reviewed for Advance Directives, placing the residents in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The facility's failure to follow their procedures for processing Advance Directives, had the potential for staff not intervening with life saving measures, (CPR [Cardiopulmonary Resuscitation]) for Resident #49 when Resident #49 wanted CPR and intervening with life saving measures (CPR) for Resident #6, when Resident #6 wanted to be a DNR [Do Not Resuscitate]. The Administrator, Director of Nursing (DON), and Regional Nurse Consultants were notified of the Immediate jeopardy on [DATE] at 9:20 PM in the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2020-03-10 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview the facility failed to ensure the prescribed tube feeding formula was available for 1 of 5 residents (Resident #77) reviewed for tube feedings when Resident #77's prescribed tube feeding was substituted with a tube feeding formula that required an increase in rate to equal the nutritional value. The increase in the tube feeding rate resulted in Resident #77's increased residuals, tube feedings held frequently, and rate had to be decreased, so the resident was not provided the required caloric intake to sustain him in his severely malnourished state, which resulted in unresponsiveness, hypoglycemia, and emergent hospitalization. The Administrator, Director of Nursing (DON), and Regional Nurse Consultants were notified of the Immediate Jeopardy (IJ) on 3/3/2020 at 7:31 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-693. The facility was cited at F-693 at a scope and severity of J, which is Substandard Quality of Care. The…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2020-03-10 · tag F0835 — failed to run the facility competently — isolated
  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 facility policy review, facility documentation review, medical record review, and interview facility administration failed to recognize, report, and investigate an abuse allegation for 1 resident (Resident #33) reviewed for reporting an abuse allegation and failed to ensure the residents' Physician Orders for Scope of Treatment (POST) forms for 2 residents (Resident #6 and #49) reviewed for Advance Directives were accurately reflected in the resident's Electronic Medical Record (EMR) regarding the residents' Code status preferences, and failed to implement a Comprehensive care plan for hypoglycemia for 1 of 38 residents (Resident #77) reviewed for Comprehensive care plans. The facility's deficient practice placed 4 residents (Resident #33, #6, #49, and #77) of 91 residents reviewed in Immediate Jeopardy (a situation where the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) and had 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2020-03-10 · tag F0867 — failed to act on quality-improvement findings — isolated
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the facility's Quality Assurance Performance Improvement (QAPI) Plan review, policy review, medical record review, and interview, the QAPI committee failed to identify deficient practice for investigating allegations of abuse for 1 of 38 residents (Resident #33) reviewed for abuse; failed to identify no person centered care plan was implemented for 1 of 38 residents (Resident #77) reviewed for care plan implementation and interventions; and failed to identify the prescribed tube feeding formula was unavailable for 1 of 5 residents (Resident #77) reviewed for tube feedings which resulted in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator, Director of Nursing (DON) and Regional Nurse Consultants were notified of the Immediate Jeopardy on [DATE] 2020 at 7:31 PM. The facility was cited Immediate Jeopardy at F-600 and F-678…

  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
• Potential for harm · Ecited before2025-07-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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 the policy review, observation, interview, and product information sheets, the facility failed to provide an environment free of accident hazards for 1of 4 common hallways (200 hall) when the facility left a bleach germicidal spray cleaner and a disinfectant spray easily accessible to residents on the 200 hall, and when unsecured sharps were observed in 5 of 52 (Resident #2, #75, #76, #88, and 90) resident rooms observed for accident hazards. There were 5 residents with wandering behaviors in the facility. The findings include: 1. Review of the undated facility policy titled, Resident Environmental Quality, revealed .It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for resident, staff and the public . Review of the facility policy titled, Sharps Disposal, dated January 2025, revealed .Whoever uses contaminated sharps will discard them immediately . into designated containers .sharps will be…

  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 · D2025-07-30 · tag F0569 — isolated
  Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
  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, resident fund statement review, medical record review, and interview, the facility failed to notify the resident and/or resident representative when the amount in the residents' account exceeded the eligibility limit for 4 of 37 residents (Resident #45, #59, #86, and #87) and when the facility failed to refund the resident's funds within 30 days of death or discharge for 1 of 1 sampled residents (Resident #103) reviewed for personal fund account statements. The findings include: 1. Review of the undated facility policy titled, Resident Trust Fund revealed, .Excess resources.Medicaid eligible residents will be notified when the amount in the resident's account reaches $200 less than the Medicaid resource limit for one person. If the amount in the account in addition to the value of the resident's other nonexempt eligibility for Medicaid or SSI [Supplemental Security Income].the resident will also be notified when this situation arises.Refunds.Upon death or discharge of a resident with a…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-30 · 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 orders to meet professional standards of practice for 7 of 21 (Resident #3, #6, #7, #11, #12, #14 and #45) sampled residents. The findings included: 1. Review of the facility policy titled, Administering Medications, dated March 2025, revealed .Medications are administered in a safe and timely manner, as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame.the following information is checked/verified for each resident prior to administering medications.vital signs, if necessary.if a drug is withheld, refused or given at a time other than the scheduled time, the individual administering medication shall initial and circle the MAR [Medication Administration Record] space provided for that drug dose.the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next one.the individual…

  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 before2025-07-30 · 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 policy review, observation, and interview, the facility failed to ensure infection control practices were followed to prevent the spread of infection when 2 of 4 (Licensed Practical Nurse (LPN) B and D) staff failed to perform hand hygiene for 3 of 9 (Resident #1, #18 and #75) residents, 2 of 4 (LPN B and Registered Nurse (RN) C) nurses failed to clean reusable equipment between residents for 2 of 9 (Resident #18 and #45) during medication administration. The findings include: 1. Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 2019, revealed .Resident-care equipment, including reusable items .will be cleaned and disinfected according to current CDC [Center for Disease Control and Prevention] recommendations for disinfection .Reusable items are cleaned and disinfected between residents .stethoscopes, durable medical equipment .Reusable resident care equipment will be sanitized in between residents . Review of the undated 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-30 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  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 ensure a safe, sanitary, and comfortable environment for 2 of 53 (Resident #5, #46, #55, and #93) shared resident bathrooms, and for 2 of 53 (Resident #64, #76, and #92) shared resident rooms observed. The findings include: 1. Review of the facility policy titled, Resident Environmental Quality, dated 2024, revealed .It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public .General Guidelines .Preventive maintenance schedules .for the maintenance of the building .should be followed to maintain a safe environment . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Diabetes, Traumatic Brain Injury, and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-11 · tag F0622 — isolated
  Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
  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 the appropriate information for transfer or discharge was communicated to the receiving healthcare facility or provider for 1 of 3 residents (Resident #7) sampled residents reviewed. Resident #7 was transferred to Hospital #1 Emergency Department (ED) on 1/29/2024 for evaluation of a change in mental status. Facility nursing staff failed to communicate information related to Resident #7's unwitnessed fall on 1/25/2024 on the written report to Hospital #1. The findings include: Review of the facility policy titled, Transfer and Discharge, revised 10/24/2022 and effective 11/20/2023 revealed, .For a transfer to another provider, the following information must be provided to the receiving provider . Other necessary information, including a copy of the resident's discharge summary, as applicable, to ensure a safe and effective transition of care .Emergency Transfers/Discharges-for medical reasons, or for 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 before2024-04-11 · 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 implement a comprehensive person-centered care plan for 3 (Resident #3, Resident #10, and Resident #15) of 20 residents reviewed. The findings include: Review of the facility's policy titled Comprehensive Care plan dated 11/30/2026 revised 10/24/2022 effective 11/9/2023, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs .'Person Centered' means to focus on the resident as the locus [focus] of control and support the resident in making their own choices and having control over their daily lives .at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Review of the medical record revealed Resident #3 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-04-11 · 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 review, medical record review, facility investigation review, hospital record review, and interview, the facility failed to assess after a fall, care for a resident after a fall, and monitor after a fall for 1 of 6 (Resident #7) sampled residents reviewed for falls. On [DATE] at 5:30 PM, Resident #7, known to have a history of falls with injury, was found on the floor following an unwitnessed fall from bed. There was no documentation to show a post-fall assessment was completed prior to moving Resident #7 from the floor to the bed. There was no documentation to show neuro checks were conducted. There was no incident report or investigation documented following the unwitnessed fall to determine the root cause. There were no immediate interventions documented following the fall. On [DATE] (4 days after the unwitnessed fall) Resident #7 was transferred to the hospital on [DATE] for a change in mental status. The findings include: Review of the facility policy titled, Accidents and…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-04-11 · 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, and interview, the facility failed to provide an environment that is free from accident hazards for 1 of 6 (Resident #7) sampled residents reviewed for falls. On [DATE] at 5:30 PM, Resident #7, known to have a history of falls with injury, was found on the floor following an unwitnessed fall from bed. LPN G documented staff (CNA AA and CNA CC) assisted Resident #7 off the floor and Resident #7 hit his head on the bed. CNA AA and CNA CC then placed Resident #7 back in bed. There was no documentation to show a post-fall assessment was completed prior to moving Resident #7 from the floor to the bed. There was no documentation to show neuro checks were conducted. There was no incident report or investigation documented following the unwitnessed fall to determine the root cause. There were no immediate interventions documented following the fall and no notification to the Physician/Nurse Practitioner (NP) 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 no plan of correction
• Potential for harm · F2021-12-15 · tag F0809 — failed to serve meals on a reasonable schedule — widespread
  Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on policy review, documentation review, and interview, the facility failed to provide a nourishing snack at bedtime between the evening and breakfast meal which was 15 hours affecting 84 of the 90 resident census. The findings include: Review of facility's policy titled, Frequency of Meals and Snacks, dated 9/1/2019, revealed, .The resident will receive adequate and frequent meals .There will be no more that 14 hours between an evening meal and breakfast the following day, unless a nourishing snack is served at bedtime; then up to 16 hours may elapse between an evening meal and breakfast the following day if the resident council agrees to this mealtime span . Review of the facility documentation, Scheduled Meal Times, dated 12/6/2021, revealed 15 hours between the dinner meal at 5:00 PM and the breakfast meal at 8:00 AM. During and interview on 12/13/2021 at 11:40 AM, the Registered Dietitian stated she was aware of the 15 hour requirement between meals and that the resident council must approve the meal times. She confirmed a resident council meeting had not taken place 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.

  Nutrition and Dietary 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

$211,244 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $211,244 — penalty dated 2024-04-11
• Medicare payment denial — starting 2024-04-17 for 8 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.

This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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