Signature Health Of Portland Rehab & Wellness Cent

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.

50.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 89 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.41 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 112 beds and averages 66.6 residents a day — about 59% occupied, or roughly 45 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.69 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.15 hrs/resident/day on weekends vs 3.91 on weekdays — 19% thinner on weekends. RN hours go from 0.91 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 68% 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.

24 citations, most serious first. The 19 most serious are shown; the remaining 5 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-04-11 · 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, hospital documentation review, facility investigation review, and interviews, the facility failed to protect the resident's right to be free from neglect for 1 of 5 sampled residents (Resident #2) reviewed. On 12/13/2023, Resident #2, a vulnerable, bilateral amputee with a diagnosis of paraplegia and neurogenic bladder sustained 3rd degree burns to 4% of his body when urine from a self-catheterization or incontinent episode contacted an energized power strip positioned in the bed with him. During interview staff confirmed episodes of urine leakage after Resident #2 self-catheterized, Resident #2 was not assessed for competency related to self-catheterization and not monitored for risk of electrocution. Staff observed the power strip in bed with Resident #2 on multiple occasions after the Administrator provided the power strip to the resident. The facility's failure to provide the necessary care and services to prevent physical harm for Resident #2 resulted…

  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 · J2025-04-11 · 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, facility investigation review, and interviews, the facility failed to initiate and provide Basic Life Support (BLS) including Cardiopulmonary Resuscitation (CPR) according to the resident's preference and physician order for 1 of 3 sampled residents (Resident #3) reviewed. On [DATE] Resident #3, a resident designated with full code status, was found unresponsive, without respirations and a palpable pulse. Nursing staff made no attempt to perform BLS/CPR in accordance with the resident's wishes/preferences. The facility's failure to provide BLS/CPR to Resident #3, a resident identified as a full code, 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 and the [NAME] Tennessee [NAME] President of Operations were notified of the Immediate Jeopardy on [DATE] at 5:08 PM…

  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 before2025-04-11 · 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, hospital documentation review, Death Certificate review, facility investigation review, observations, and interviews, the facility failed to provide supervision and ensure the environment remained free of accident hazards to prevent avoidable accidents for 5 of 5 sampled residents (Residents #1, #2, #12, #14, and Resident #15) reviewed for accidents. On [DATE], Resident #2, a vulnerable, bilateral amputee with a diagnosis of paraplegia and neurogenic bladder was electrocuted while lying in bed. Resident #2 sustained 3rd degree burns to 4% of his body when urine contacted an energized power strip (provided by the Administrator) positioned in the Resident's bed with him. Resident #1 was a vulnerable, cognitively impaired, and legally blind resident at high risk for falls. On [DATE] staff assisted Resident #1 to the bathroom and left her unattended. Resident #1 stood up and fell to the floor. Resident #1 sustained a left pubic root fracture [bones making up…

  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 before2024-08-23 · 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, manufacture's guidelines review, printed text message review, medical record review, and interview, the facility failed to protect the resident's right to be free from neglect for 1 of 3 (Resident #1) sampled residents reviewed. The facility failed to provide the necessary structure and processes to meet the care needs of Resident #1, a vulnerable resident with a diagnosis of Paraplegia, when on 7/28/2024, 7/29/2024, 8/11/2024, and 8/12/2024 staff observed the hot water heater located in the Station 2 shower room, leaking/gushing hot water/steam from the tank onto the resident care area. The Station 2 shower room remained in use from 7/28/2024 through 8/1/2024 pending repair and on 8/11/2024 and on the morning of 8/12/2024 staff observed hot water and steam leaking/gushing out of the hot water heater located in Station 2 shower room again. The Station 2 shower room remained in use and on 8/12/2024, at approximately 1:30 PM (six hours later) Resident #1 sustained second degree…

  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 before2024-08-23 · 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, hot water heater service manual review, medical record review, facility investigation review, facility Event Report review, Facility Maintenance Logbook Documentation, and interviews, the facility failed to ensure the residents' environment remained free of accident hazards as evidenced by dangerous hot water temperatures in the Station 2 shower room that were measured at 169 degrees Fahrenheit at the time of the incident for 1 (Resident #1) of 10 sampled residents reviewed for accident hazards. On 8/12/2024, Resident #1, a vulnerable resident with a diagnosis of paraplegia was sitting on a shower chair when the hot water tank sprayed scalding hot water on the floor of the shower room where Resident #1 was sitting. Resident #1 sustained second (2nd) degree burns to left plantar area of the left foot. The facility's failure to provide an environment that was free from accident hazards over which the facility had control and prevent avoidable accidents resulted in 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-08-23 · 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 the Board of Examiners of Nursing Home Administrators (BENHA) review, job description review, and interview, Administration failed to provide the oversight and supervision of staff to protect the resident's right to be free from neglect and failed to meet the care needs of residents in a safe environment when staff continued to provide Resident #1's showers in the Station 2 shower room which contained a malfunctioning hot water heater. Administration failed to provide oversight and supervision to provide an environment free from hazards and prevent an avoidable accident when the hot water heater in Station 2 shower room experienced a mechanical failure causing scalding hot water to [NAME] onto the floor where Resident #1 was receiving a shower resulting in a major burn injury to Resident #1's left foot. Administration's failure to provide oversight and supervision resulted in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has…

  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
• Actual harm · G2025-12-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, hospital record review, observation, and interview, the facility failed to provide care and services to prevent the development of a pressure ulcer/injury for 1of 4 (Resident #4) sampled residents reviewed for pressure ulcers. On 8/20/2025, Resident #4, a resident with impaired mobility who was at risk for pressure ulcers, was readmitted to the facility with an immobilizer to her left lower leg. The facility failed to assess, monitor, and document Resident #4's skin integrity underneath the immobilizer daily from 8/21/2025 to 9/8/2025, resulting in a pressure injury and an infection to the left lateral (outside portion of leg) ankle which resulted in actual Harm to Resident #4. The findings include: 1. Review of the facility policy titled, Splints and Braces, dated 1/31/2025, revealed .Staff will ensure proper application, monitoring, maintenance, and documentation of all splints and braces to promote resident safety, comfort, and functional ability. Review of 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
• Actual harm · G2025-09-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  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 review, facility policy review, Vitals Report, Patient Weight Reports review, Weight Intervention Audits, Weight (wt.) Loss Documentation Report review, medical record review, and interview, the facility failed to assess and address a resident's nutritional status and implement pertinent interventions when 1 of 16 (Residents #1) sampled residents reviewed for nutritional needs sustained severe weight loss. Resident #1 experienced a severe weight loss of 7.07% from February 12, 2025, to February 19, 2025 (a period of one week). The facility's failure resulted in actual Harm to Resident #1. The findings included: 1. Review of the Job Description for the Registered Dietitian dated revealed, .The registered dietitian has administrative authority, responsibility, and accountability necessary to carry out assigned duties. Responsibilities include planning, organizing, developing, and directing the nutritional care of the resident in accordance with current federal, state, and local…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2019-02-07 · 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 facility policy review, manufacturer's guidelines, medical record review, observation and interview, the facility failed to provide supervision to prevent an injury during a transfer with a sit to stand lift resulting in a fracture and (Harm) for 1 Resident (#77) of 6 residents reviewed for accidents. The findings include: Review of the facility policy, Resident Lift, dated 5/30/18 revealed .At least (2) trained staff are needed to transfer a resident when using a Lift .5. Ensure that sling is placed on resident according to manufacturer's guidelines . Review of the manufacturer's guideline, Stand Up Patient Lift dated 2010 revealed .Be sure to check the sling attachments each time the sling is removed and replaced, to ensure that it is properly attached before the patient is removed from a stationary object (bed, chair, or commode) .Before lifting a patient from a stationary object (wheelchair, commode or bed), slightly raise the patient off the stationary object and check that all sling attachments…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-04 · 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, review of Center for Disease Control (CDC) website guidelines, medical record review, observation, and interview, the facility failed to ensure the prevention and spread of infection when 1 of 1 staff (Assistant Director of Nursing (ADON)) failed to perform hand hygiene and failed to use appropriate Personal Protective Equipment (PPE) while performing wound care for 2 of 2 (Residents # 4 and #16) sampled residents reviewed. The findings include: 1.Review of the facility policy titled, Enhanced Barrier Precautions, dated 1/30/2024, revealed .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.Enhanced Barrier Precautions (EBP) are additional measures to attempt to decrease transmission of Multidrug-Resistant Organisms (MDRO).If a resident is placed on EBP, appropriate signage is placed at the room entrance so that…

  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 · F2025-04-11 · 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

  Based on policy review, Quality Assurance and Performance Improvement (QAPI) report, observations, and interview, the QAPI committee failed to ensure systems and processes were in place that implemented and monitored identified interventions for improvement activities to provide a safe environment for residents and failed to provide adequate supervision to ensure staff provided QAPI interventions for a safe environment. The findings included: 1. Review of the facility's policy titled, Quality Assurance/Performance Improvement (QAPI) Program Policy, revised 9/15/2023, revealed, .To provide a process that will enhance the care and experience for all residents .quality of all services provided by the facility .It is the intent of this facility to conduct an on-going Quality Assurance/Performance Improvement (QAPI) program designed to systematically monitor, evaluate and improve the quality and appropriateness of resident care .Documentation of items discussed at the QAPI meeting will be maintained by the facility Administrator . 2. Review of an Event Report dated 12/14/2023 revealed 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-11 · 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, facility investigation review, medical record review and interviews, the facility failed to ensure neglect with physical harm was reported to the State Survey Agency (SSA) in accordance with Federal and State law for 1 of 3 sampled residents (Resident #2) reviewed. The findings included: 1. Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, revised 9/15/2023, revealed .It is the organization's intention to prevent the occurrence of abuse, neglect .and to assure that all alleged violations of federal or State laws which involve .neglect .are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law .The Facility Administrator is responsible for reporting all investigations' results to applicable State agencies as required by Federal and State law .Abuse also includes the deprivation by an individual, including a caretaker,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-11 · tag F0626 — isolated
  Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
  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, hospital documentation review, and interview, the facility failed to permit 1 of 3 sampled residents (Resident #4) reviewed for discharges to return to the facility after hospitalization. The findings included: 1. Review of the facility's policy titled, Transfer/Discharge Notice, revised 2/3/2025, revealed, .The facility is committed to ensuring that all transfers and discharges are conducted in a manner that respects the rights .of residents .while complying with federal and state regulations .The facility must permit each resident to remain in the facility, and not .discharge the resident from the facility unless .The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included Osteomyelitis of vertebra, sacral and sacrococcygeal region,…

  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 · F2020-01-29 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, the facility failed to handle food in a sanitary manner for 1 (Resident #1) of 2 residents observed on the secure unit, and failed to maintain dietary equipment in a sanitary manner. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE], with diagnosis which included Dementia, Anxiety Disorder, and Muscle Weakness. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 required extensive assistance with one staff member with meals. Observation on 1/27/2020 at 1:20 PM, in the secure dining room revealed Certified Nurse Aide (CNA) #3 setting up Resident #1's lunch tray. Further observation revealed the CNA picked up the resident's sandwich, took it out of the sandwich bag with her bare hands, and placed it on the plate. Interview with CNA #3 on 1/27/2020 at 1:26 PM, in the secure unit day room confirmed gloves should be worn when handling resident's food. Interview…

  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 before2020-01-29 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to accurately assess a fall with no injury on the Minimum Data Set (MDS) for 1 resident (Resident #60); and failed to accurately identify the discharge location on the MDS for 1 resident (Resident #64) of 33 residents reviewed. The findings include: Medical record review revealed Resident #60 was admitted to the facility on [DATE], with diagnoses which included Seizures, Atrial Fibrillation, Repeated Falls, Vascular Dementia, Fracture Neck Right Femur, Stable Burst Fracture T 11 - T 12 (Thoracic vertebra number 11 and 12), and Urinary Tract Infection. Medical record review revealed on 8/5/2019, Resident #60 was found on the floor in her room with no apparent injury. Medical record review of the Annual MDS dated [DATE], revealed the section addressing falls failed to address any fall(s) since the prior review on 6/19/2019. Interview with the MDS Coordinator on 1/29/2020 at 1:10 PM in her office confirmed the 9/7/2019 MDS, failed to address the fall…

  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 · D2020-01-29 · 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 have a comprehensive care plan related to discharge preferences for 1 (Resident #64) of 33 residents reviewed. The findings include: Facility policy review, Comprehensive Care Plans, revised on 7/19/2018, revealed .The resident's preference, potential for discharge and return to the community will be evaluated. Referrals made to the local agencies or entities will be documented as indicated . Medical record review revealed Resident #64 was admitted to the facility on [DATE] with diagnoses which included Dementia without Behavioral Disturbance, Paraplegia, Type 2 Diabetes Mellitus, and Pressure Ulcer of Sacral Region. Medical record review of the physician telephone orders dated 11/12/19 revealed .Patient d/c [discharge] home with skilled nursing and wound care with home health . Medical record review revealed no discharge care plan. Interview with the MDS Coordinator on 1/29/2020 at 2:36 PM, in the conference room…

  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 · D2020-01-29 · 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, observation and interviews, the facility failed to obtain a physician's order for Oxygen [02] at 3 Liters [L] per minute for 1 (Resident #36) resident of 24 residents who received respiratory services. The findings include: Facility policy review, General Medication Orders, dated 6/26/2018, revealed .The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders .A current list of orders must be maintained in the clinical record of each resident .Oxygen Orders - When recording orders for oxygen, specify the rate of flow, route and rationale . Medical record review revealed Resident #36 was re-admitted on [DATE] with diagnoses which included Chronic Respiratory Failure, Chronic Diastolic (Congestive) Heart Failure, Dependence On Supplemental Oxygen, Chronic Obstructive Pulmonary Disease And Obstructive Sleep Apnea. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2020-01-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation and interviews, the facility failed to properly store and date respiratory equipment to prevent the spread of infection for 3 (Resident #4, #36 and #62) of 24 residents who received respiratory services. The findings include: Facility policy review, Policies and Practices - Infection Control, dated October 2018, revealed .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment .Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Dementia with Behavioral Disturbances and Thrombocytopenia . Medical record review of the physician orders dated January 2020, revealed .ipratropium-albuterol 0.5 mg [milligram] - 3 mg (2.5 mg base) / 3 mL [milliliter] 1 Vial Every 6 Hours . Observation on 1/27/2020 at 9:37 AM and at…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2020-01-29 · tag F0908 — failed to keep essential equipment working — isolated
  Keep all essential equipment working safely.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation and interview, the facility failed to maintain the heated plate lowerator in a safe operational condition. The findings include: Observation and interview with the Certified Dietary Manager on 1/29/2020 at 9:20 AM, in the dietary department confirmed 1 of 2 of the heated plate lowerator lids was bent and could not form a proper seal to ensure adequate heating.

  Environmental 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

$171,234 in federal fines across 5 penalties. 1 Medicare payment denial on record.

• $53,138 — penalty dated 2025-12-04
• $10,868 — penalty dated 2025-09-11
• $91,582 — penalty dated 2025-04-11
• $7,823 — penalty dated 2024-08-23
• $7,823 — penalty dated 2024-08-23
• Medicare payment denial — starting 2024-08-29 for 2 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.

Part of a chain

This home belongs to SIGNATURE HEALTHCARE — 67 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

5 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.

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 14% 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.

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