Eaton 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.

Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 37% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at 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 124 beds and averages 99.6 residents a day — about 80% occupied, or roughly 24 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 5.04 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.94 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 5.08 hrs/resident/day on weekends vs 5.02 on weekdays — about the same on weekends as weekdays. RN hours go from 0.59 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% is about the same as 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.

36 citations, most serious first. The 21 most serious are shown; the remaining 15 are one tap away and print in full.

• Immediate jeopardy · L2024-11-07 · tag F0600 — failed to protect residents from abuse and neglect — widespread
  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, Facility #1 medical record review, facility investigation review, Hospital #2 medical record review, Facility #2 medical record review, Emergency Medical Services (EMS) report review, police report review, and interview the facility failed to provide an environment free from all types of abuse including, deprivation of goods and services by staff, sexual abuse by a resident, physical abuse by a family member, and verbal abuse by a staff member for 7 of 21 sampled residents (Resident #4, #5, #2, #3, #35, #19, and #49) reviewed for abuse. On 7/7/2024, Certified Nursing Assistant (CNA) O entered Resident #5's room and saw Resident #4 with her face leaning over the groin area of Resident #5, who quickly pulled up his pants when the CNA entered the room. CNA O failed to immediately intervene and left the two residents alone. The Facility failed to supervise Resident #4, a cognitively impaired resident, that exhibited wandering tendencies to prevent the resident from entering in other…

  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 · L2024-11-07 · tag F0835 — failed to run the facility competently — widespread
  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 the Board of Examiners of Nursing Home Administrators (BENHA) review, list of Director of Nursing (DON) staff, job description review, facility policy review, Quality Assurance Performance Improvement (QAPI) Plan, Licensed Independent Practitioner Scope of Services, and interview, the facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of vulnerable residents in the facility. The facility Administration failed to provide oversight of clinical staff and follow-up on a resident with a recent long and severe history of illicit/street drug abuse. The facility Administration failed to provide oversight of staff to prevent all types of abuse of vulnerable and cognitively impaired residents in the facility, to intervene immediately in observed abuse, and to timely report allegations of abuse. The facility Administration'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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · L2024-11-07 · tag F0837 — widespread
  Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on facility policy review, Quality Assurance Performance Improvement (QAPI) meeting minutes review, and interview, the facility ' s Governing Body consisting of the present Administrator, Senior [NAME] President of Operations, Regional Director of Operations, Assistant [NAME] President of Clinical Operations, Regional Nurse Manager, Assistant Director of Nursing, and the Director of Nursing failed to provide oversight for the QAPI Program to ensure an effective QAPI plan was established and implemented to address, timely report, and thoroughly investigate allegations of sexual abuse, physical abuse, and neglect. The Governing Body failed to ensure the QAPI Program established and implemented effective interventions to address nutritional needs for vulnerable residents that resulted in significant weight loss. The failure of the facility ' s Governing Body 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…

  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 · Lcited before2024-11-07 · tag F0867 — failed to act on quality-improvement findings — widespread
  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 policy review, job description review, Quality Assurance and Performance Improvement (QAPI) Minutes review, QAPI sign-in sheets, facility investigation, and interview, the QAPI Committee failed to ensure an effective QAPI program that systematically identified, reported, tracked, investigated, analyzed and used data and information related to all types of abuse and nutritional status in the facility. The QAPI committee failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently. 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) was identified in relation to the QAPI committee ' s failure ensure residents were free from abuse and neglect when staff observed Resident #4 sitting on Resident #5 ' s bed with her face over his exposed groin area, failed to intervene, and left 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 · K2024-11-07 · tag F0609 — failed to report abuse allegations — pattern
  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, facility investigation review, and interview, the facility failed to timely report allegations of abuse and neglect for 5 of 21 (Resident #2, #3, #19, #4, and #5) sampled residents reviewed for abuse. The facility failed to report an allegation of sexual abuse to the State Survey Agency within 2 hours when Resident #2 reported/alleged to staff on 5/8/2024 at approximately 11:00 PM that Resident #3 assaulted her through anal penetration. The facility failed to report Resident #19 ' s cocaine overdose in the facility on 11/8/2023 at approximately 8:30 PM, within 2 hours to the State Survey Agency. The facility ' s failure to ensure all allegations of abuse and neglect were reported immediately resulted in an Immediate Jeopardy (IJ) for Resident #2, #3, and #19. An 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, impairment, or death…

  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 before2024-11-07 · tag F0610 — failed to investigate and act on abuse reports — pattern
  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, facility investigation review, medical record review, and interview, the facility failed to conduct a thorough investigation and take appropriate corrective actions for 6 of 21 (Resident #4, #5, #2, #3, #7 and #19) sampled residents reviewed for abuse. The facility failed to conduct a thorough investigation into an allegation of sexual abuse between Resident #4, a vulnerable, cognitively impaired resident with a diagnosis of dementia, and Resident #5 on 7/7/2024. The facility failed to conduct a thorough investigation into Resident #2's allegation that Resident #3 sexually assaulted her through anal penetration on 5/8/2024, which resulted in psychosocial harm and delayed incontinence care for the victim. The facility failed to conduct a thorough investigation into Resident #19's cocaine overdose in the facility on 11/8/2023. The facility's failure to perform a thorough investigation resulted in an Immediate Jeopardy for Resident #4, #5, #2, #3, #7, and #19. Immediate Jeopardy…

  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 · K2024-11-07 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
  Provide enough food/fluids to maintain a resident's health.
  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 job description, facility policy review, ADL (Activities of Daily Living) Verification Worksheet, Patient Weight Reports, Weight (wt) Loss Documentation Report, medical record review, observation and interview, the facility failed to recognize repeated, systemic failures to assess and address a resident ' s nutritional status and to implement pertinent interventions that resulted in continued significant weight loss for 5 of 9 (Residents #67, #65, #63, #45 and #46) sampled residents reviewed for nutritional needs. Resident #45 experienced a significant weight loss of 10% (percent) in 6 months. Resident #67 suffered a significant and severe weight loss of approximately 9.0% over 2 months from 8/15/2024 to 10/14/2024. Resident #65 suffered a significant and severe weight loss of approximately 8.5% over 1 month from 8/9/2024 to 9/13/2024. Resident #63 suffered a significant and severe weight loss of approximately 10.19% over 3.5 months from 2/5/2024 to 5/20/2024. Resident #45 suffered 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-11-07 · 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, record review, medical record review, observation, and interview, the facility failed to ensure a safe, secure environment for a vulnerable and high-risk resident with wandering behaviors for 1 of 5 sampled residents (Resident #1) reviewed for elopement/wandering. The facility's failure to ensure a safe, secure environment resulted in Immediate Jeopardy (IJ) when Resident #1 exited the facility through the window in his room. Resident #1's sister called the facility around 5:30 AM to notify the facility that Resident #1 was found sitting on her front porch which was approximately 3 miles from the facility, along highly trafficked city streets and in a heavily populated area. Facility staff were unaware Resident #1 had exited the facility for approximately 8 and a half hours. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2023-08-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, facility document review, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision for 1 (Resident #29) of 7 sampled residents reviewed for wandering/elopement. The facility's failure to supervise and prevent Resident #29, with a known history of exit seeking behaviors and who was actively exhibiting delusions and auditory hallucinations from eloping to an unsafe environment, resulted in Immediate Jeopardy (IJ) when Resident #29 was found outside of the facility in the parking lot at 9:15 PM on 9/24/2022. According to staff statements, the resident was last seen in her wheelchair ambulating through the facility hallways around 8:30 PM. The facility's staff were unaware Resident #29 had exited the facility until a food delivery service driver alerted a staff member the resident was in the parking lot in a wheelchair near the exit/entrance gate. Resident #29 was exhibiting exit seeking behaviors, delusions,…

  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 · Past Non-Compliance
• Immediate jeopardy · Jcited before2023-08-30 · 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

  Amended from F-865 to F-867 Based on facility policy review, facility document review, medical record review, and interview, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to develop an effective QAPI program that recognized concerns related to exit seeking behavior when a resident exited the facility without staff knowledge, and failed to provide adequate supervision to prevent elopement and failed to ensure a safe environment for 1 (Resident #29) of 7 sampled residents. Failure of the QAPI Committee to provide adequate supervision to prevent elopement placed Resident #29 in Immediate Jeopardy. Resident #29 (a resident who was experiencing auditory hallucinations and delusions, with known wandering and exit seeking behaviors) was able to exit the facility to the parking lot at night on 9/24/2022. The whereabouts of Resident #29 was unknown by staff from approximately 8:30 PM to 9:15 PM. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause,…

  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 · Past Non-Compliance
• Actual harm · Gcited before2025-02-06 · 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 adequate supervision and assistance to prevent a fall accident for 1 of 3 residents (Resident #1) reviewed for accidents. On 1/21/25, Certified Nursing Assistant (CNA) V attempted to transfer Resident #1 from a shower bed to Resident #1's bed without assistance from another staff member and failed to lock all the shower bed wheels properly. Resident #1 fell between the beds and sustained an acute mildly displaced (pieces of bone moved so much that a gap formed when the bone broke) fracture (a partial or complete break in the bone) involving the left humeral neck (part of the long bone in the upper arm that connects the head with the shaft of the bone) with adjacent (next to the broken bone) soft tissue swelling (localized inflammation in the body's soft tissues, such as muscles, tendons, and ligaments), bruises on front side of chest, front and back of upper…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-04 · 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 facility policy review, a nourishment room posted note, observations, and interviews, the facility failed to maintain dietary equipment in a sanitary manner and failed to ensure food was stored and labeled in a manner to prevent the spread of infection when foods were found uncovered, unlabeled, and undated, in a refrigerator in the kitchen and in the nourishment room refrigerator. This facility had a census of 99, with 94 residents receiving a tray from the kitchen. The findings include: Review of the facility policy titled, Food Preparation and Service, dated 11/2022, revealed .Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices.Food Preparation Area.cleaning and sanitizing.food-contact equipment between uses.Food Distribution and Service.labeling all food brought in.for residents. Review of the facility policy titled, Food Receiving and Storage, dated 11/2022, revealed .Food services, or other designated staff, maintain clean.appropriate food storage areas at all times.Dry Food Storage.Dry…

  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 · Dcited before2026-03-04 · 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, observation, and interview, the facility failed to provide an environment free of hazardous materials for 7 of 99 (Resident #19, #55, #66, #73, #83, #93, and #98) sampled residents for accident hazards. The findings include: 1. Review of the facility policy titled, Hazardous Areas, Devices and Equipment, dated 2001, revealed .All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible.A hazard is defined as anything in the environment that has the potential to cause injury or illness.Examples of environmental hazards include.Sharp objects that are accessible to vulnerable residents. 2. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Diabetes, Depression, and Parkinson's Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-04 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to store medication in accordance with facility policy when medication was found unsecured in the resident's room for 1 of 99 (Resident #33) sampled residents. The findings include: 1. Review of the facility policy titled, Medication Labeling and Storage, dated February 2023, revealed .The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.the nursing staff is responsible for maintaining medication storage. 2. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Congestive Heart Failure, Depression, and Anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #33 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was cognitively intact. Resident #33…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-11-07 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  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 investigation summary review, medical record review, and interview, the facility failed to ensure 1 (Resident #26) of 3 residents reviewed were free from misappropriation. The findings include: Review of the facility policy titled, Abuse Prohibition Plan revised 10/24/2022 revealed, .The resident shall not be subjected to .misappropriation of property .The .policy applies to anyone involved with the residents of this facility, including .all .staff .Misappropriation of Resident Property means the deliberate misplacement, exploitation .use of a resident's belongings .without the resident's consent . Review of the facility policy titled, Medication Administration: Narcotic Control Record revised 10/9/2023 revealed, .The facility shall have safeguards in place in order to prevent .diversion .The facility shall utilize the Narcotic Control Record so that all controlled medications can be reconciled and counted at the change of each shift .The total number of narcotic sign…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-11-07 · 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 reviews, and interviews, the facility failed to ensure transfer/discharge information was documented in the medical record and communicated to the receiving provider for 6 of 6 residents (Resident #44, #43, #52, #53, #54 and #51) reviewed for transfer/discharge. The findings include: Review of the facility's policy titled, Transfer and Discharge revised 10/24/2022, revealed, . Emergency Transfers/Discharges-for medical reasons, or for the immediate safety and welfare of a resident .Obtain physicians ' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis .Complete and send with the resident a Transfer to Hospital Form which documents .Current diagnosis and reasons for transfer .Contact information of the practitioner responsible for the care of the resident . Resident representative information including contact information . Current medications, treatments, labs and or radiological findings, 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 · Dcited before2024-11-07 · tag F0625 — isolated
  Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to provide a bed-hold notice to the resident or resident representative at the time of transfer for 5 of 6 residents (Resident #43, #52, #53, #54, #51) reviewed for discharge. The findings include: Review of the facility policy titled, Bed Hold Notice Prior to and Upon Transfer, revision date 7/31/2023 revealed, .It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident . At the time of transfer for hospitalization or therapeutic leave, the facility shall provide to the resident and/or the resident representative written notice . Review of medical record revealed, Resident #43 was admitted to the facility on [DATE] with a diagnosis: Unspecified Dementia, Type 2 Diabetes, Anxiety Disorder, Chronic Kidney Disease. Record review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #43 had 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 before2024-11-07 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interviews, the facility failed to update the care plan for 2 (Resident #45and #56) of 70 sampled residents reviewed for care plans. The findings included: Review of the facility policy titled, Comprehensive Careplan, with effective date 11/09/2023 revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and time frames to meet a resident ' s medical, nursing .needs that are identified in the resident ' s comprehensive assessment. Our resident person-centered plan of care includes the Comprehensive care plan and the Resident care needs . Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, Nutritional Deficiency, and Gastro-Esophageal Reflux Disease (GERD) without Esophagitis. Review of a Clinical Note for Resident #45 dated 3/27/2024 at 1:21 PM, revealed,…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-11-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the facility policy review, medical record review, and interviews, the facility failed to provide a resident who was unable to carry out activities of daily living (ADL) the necessary services to maintain personal hygiene for 1 of 5 (Resident #33) residents reviewed for bathing. The findings included: Review of the facility policy titled Activities of Daily Living dated 4/17/2024, revealed .Care and services shall be provided for the following activities of daily living: Bathing, dressing, grooming .A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good .personal .hygiene . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Therapy, Diabetes Mellitus with Hypoglycemia and Acute Embolism and Thrombosis of Deep Vein. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #33 .was dependent for .toileting hygiene, personal hygiene 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 before2024-11-07 · 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 reviews, and interviews, the facility failed to provide a physician order to administer medication for 2 of 7 residents (Resident #43 and Resident #8) reviewed for physician orders. The findings include: Review of the facility's policy titled, Physician Verbal Order Policy, revised on 4/18/2024 revealed, .Immediately read-back of the orders to the physician or health care provider .Enter the order into the medical record manually or electronically .Write T.O. (telephone order) or V.O. (verbal order), including date, time, name of the resident, the complete order; and sign the name of the physician or health care provider and nurse or sign off the electronic order as per the software system guidelines .physician should sign the order on his/her next visit to the facility or within the time frame required by the facility . Review of the facility's policy titled, Medication Administration, revised on 8/4/2023 revealed, .Medications shall be administered . per the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-11-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the facility policy review, medical record review, and interviews, revealed the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcer for 2 (Resident #31 and Resident #33) of 9 residents reviewed for wound care. The findings include: Review of medical records revealed Resident #31 was admitted to the facility on [DATE] with diagnoses which included Acute Diastolic Heart Failure, Morbid Obesity, and Protein Calorie Malnutrition. Review of the Care Plan dated 2/19/2024, revealed Resident #31 revealed .at risk for malnutrition/hydration/weight loss related to GERD .Morbid Obesity, mechanically altered Diet, Daily Diuretics .risk for impaired skin integrity .weekly skin audits .has Stage 4 pressure ulcer to coccyx .assess size 1 time weekly . Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 14, which…

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

  Quality of Life and Care 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

$135,407 in federal fines across 5 penalties. 1 Medicare payment denial on record.

• $6,582 — penalty dated 2026-03-04
• $6,583 — penalty dated 2026-03-04
• $15,512 — penalty dated 2025-02-06
• $95,384 — penalty dated 2024-11-07
• $11,346 — penalty dated 2023-08-30
• Medicare payment denial — starting 2024-11-14 for 25 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

CMS files one row per role, so the 16 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

About 80% 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 $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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