Lauderdale Community Living Center
215 Lackey Lane Po Box 186, Ripley, TN 38063 · For profit - Limited Liability company · 71 certified beds · (731) 635-5100 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0606), cited Mar 2023
- it has a citation for mishandling residents’ money or property (F0569)
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $43,644 in federal fines (most recent 2025-08-14)
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- about 19% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 28.1% | 14.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.4% | 6.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.8% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.9% | 13.8% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.4% | 3.4% | 3.3% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 47.2% | 31.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 88.2% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.6% | 5.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 15.2% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.5% | 16.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 19.2% | 1.7% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 45.5% | 79.8% | 79.4% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 71 beds and averages 32.6 residents a day — about 46% occupied, or roughly 38 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 2.99 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.49 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 2.64 hrs/resident/day on weekends vs 3.14 on weekdays — 16% thinner on weekends. RN hours go from 0.52 to 0.49 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%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-08-14 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 (Named Glucometer-a device/meter used to check blood sugar levels with the use of a blood sample) User's Guide review, policy review, job description review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when a multi-use blood glucose meter was not cleaned and disinfected with an Environmental Protection Agency (EPA) approved disinfecting wipe to prevent the cross-contamination of bloodborne pathogens for 2 of 2 (Residents #2 and Resident #15) sampled residents reviewed for blood glucose monitoring. Licensed Practical Nurse (LPN) A failed to clean and disinfect the multi-use blood glucose meter before and after use on each resident in accordance with User's Guide recommendations and facility policy. LPN B failed to perform hand hygiene and glove changes between medication administration of different routes, failed to clean, rinse, and dry a nebulizer mask after use, and failed to perform hand…
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.
- Immediate jeopardy · Jcited before2025-05-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, facility investigation review, timeanddate.com weather website review, police report review, observation, and interview, the facility failed to provide adequate supervision to ensure the resident environment was free of accident hazards for 1 of 3 (Resident #1) residents reviewed with wandering/exit seeking behaviors. On 2/9/2025 between 7:00 PM and 7:20 PM, Resident #1, a vulnerable resident with Dementia, who experienced hallucinations, exit seeking behaviors and was cognitively impaired, eloped through an unlocked and unsecured door that malfunctioned on C Hall. Resident #1 exited the facility, left his wheelchair at the door, went down a steep embankment, and was found on the ground at the driveway entrance, beside a two-way street, and sustained head injuries that required hospital transfer and evaluation in the local Emergency Department (ED). The temperature outside on 2/9/2025, between 7:00 PM and 7:20 PM, was 37 degrees Fahrenheit. Resident #1 was observed,…
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.
- Potential for harm · E2025-08-14 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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, employee timesheets, and interview, the facility failed to provide sufficient nursing staff with appropriate competencies and skill sets to ensure residents attain or maintain the highest level of practicable physical well-being when the facility failed to ensure that a Cardiopulmonary Resuscitation (CPR) certified staff member was working 24 hours per day for 16 of 40 days reviewed. The facility had a census of 35 upon entrance. The findings include: 1. Review of the policy titled, Staffing, dated 10/2017, revealed .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. 2. Review of the employee timesheets dated [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], and [DATE]-[DATE], revealed there was not a CPR certified staff member working in the facility for 24 hours for the dates as follows:…
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.
- Potential for harm · E2025-08-14 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, employee time sheet review, State of Tennessee Department of Health Division of Health Licensure website review, and interview the facility failed to ensure a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, for 15 of 54 days reviewed and failed to ensure the Director of Nursing (DON) had a current and active nursing license from [DATE]-[DATE]. The findings include: 1. Review of the facility policy titled Staffing, dated 10/2017, revealed .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents. 2. Review of the employee time sheets dated [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], and [DATE]-[DATE], revealed there was no RN on duty for 8 consecutive hours on the following dates : a. [DATE] b. [DATE] c. [DATE] d. [DATE]…
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.
- Potential for harm · Ecited before2025-08-14 · tag F0732 — patternPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on daily staffing sheet review, observation, and interview, the facility failed to post daily staffing sheets that included the number of actual hours worked by each discipline for 31 of 31 days. The findings include: Review of the facility's posted daily staffing sheets dated 7/12/2025-8/11/2025, revealed the actual number of hours worked by Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNA) was not included. Observations in the facility's front entrance lobby on 8/11/2025 at 10:30 AM, 8/12/2025 at 7:30 AM, and 8/13/2025 at 7:30 AM, revealed the posted daily staffing sheet did not include the actual number of hours worked by the RN, LPN, and CNA. During an interview on 8/13/2025 at 5:43 PM, the Director of Nursing (DON) confirmed the posted daily staffing sheet should include the actual number of hours worked by the RN, LPN, and CNA. Observation in the facility's front entrance lobby on 8/14/2025 at 7:30 AM, revealed the posted daily staffing sheet did not include the actual number of hours worked by the RN, LPN, and CNA.
- Potential for harm · E2025-08-14 · tag F0802 — failed to prepare enough nourishing food — patternProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, observation, and interview, the facility failed to provide sufficient staff with the competencies and skill sets to carry out the functions of the food and nutrition services when there was not a Dietary Manager employed in the kitchen. The facility had a census of 35 with 35 of those residents receiving a meal tray from the kitchen. The findings include: Review of the facility policy titled, Staffing, with a revision date of 10/22, revealed .Other support services ( .dietary, activities/recreational.staff to ensure resident needs are met. Observations in the Kitchen on 8/11/2025 at 9:15 AM, 8/12/2025 at 10:30 AM, and 8/13/2025 at 2:10PM, revealed the kitchen had no standard cleaning schedules, this was evident by large plastic containers holding dry food items with dried substances and loose particles on top of the lids and down sides of containers; when stainless steel tables, metal storage racks, and the steam table shelf, were found with dried, splattered substances on their surfaces, the walk in dry storage area had a dried white powdery substance on 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.
- Potential for harm · E2025-08-14 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility menu review, observation, and interview, the facility failed to serve food items from the menu posted for 3 out of 3 days reviewed during the recertification survey. The census was 35 with 35 residents receiving meals. The findings include: Review of the facility lunch menu dated 8/11/2025, revealed Beef Ravioli with sauce, seasoned green beans, bread/roll, butter/margarine, and frosted cake. The menu was changed by the Registered Dietitian at 9:15 AM on 8/11/2025, due to lack of food items needed to fill the posted menus for 8/11/2025, 8/12/2025, and 8/13/2025. Observation of the lunch menu on 8/11/2025, revealed meat loaf, sweet potatoes, sugar snap peas, bread/roll, butter/margarine, and frosted white cake. Review of the facility lunch menu dated 8/12/2025, revealed pork riblet with barbeque (BBQ) sauce, savory green rice, seasoned succotash, and creamy raspberry dessert. Observation of the lunch menu on 8/12/2025, revealed roast pork, savory white rice, black eyed peas, bread/roll, butter/margarine, and blue berry dessert. Review of the facility lunch menu…
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.
- Potential for harm · Ecited before2025-08-14 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 policy review, observation, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions, when large plastic containers holding dry food items revealed dried substances and loose particles on top of the lids and down the sides of the containers; when stainless steel tables, metal storage racks, and the steam table shelf, were found with dried, splattered substances on their surfaces; and when the walk in dry storage area had a dried white powdery substance on the floor and on top of 2 brown boxes located on a shelf. The outside of the ICE machine contained dried liquid spills down the front and both sides and the inside of the ICE machine contained several white streaks running down the inside walls around the door area. Clean dishes were stored in an area where dirty dishes were being washed. The side-by-side refrigerator contained four opened liquid containers with no open date on the containers. The Facility failed to maintain a complete, 3-day…
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.
- Potential for harm · E2025-08-14 · tag F0867 — failed to act on quality-improvement findings — patternSet 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 review of Quality Assurance and Performance Improvement (QAPI) Performance Improvement Plan meeting minutes, policy review, observation and interview, the QAPI Committee failed to recognize ongoing problems of inadequate supervision, failed to provide oversight to ensure an effective Infection Control Program was in place that protected residents from cross contamination and failed to ensure staff were competent in providing resident care. The QAPI committee failed to identify the root cause of the problems identified, failed to develop appropriate plans to correct the identified problems, failed to ensure systems and processes were implemented to address, correct, and maintain acceptable standards of practice, and failed to provide clinical guidance and oversight regarding the implementation of resident care policies and procedures. The QAPI Committee failed to ensure community medical equipment was disinfected to prevent the potential spread of infection when Licensed Practical Nurse (LPN) A failed to clean a multi-use blood glucose meter according to manufacturer'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.
- Potential for harm · D2025-08-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 policy review, medical record review, observation, and interview, the facility failed to implement interventions on the care plan for 1 of 5 (Resident #25) sampled residents reviewed for Hydration and Nutrition. The findings include: 1. Review of the undated facility policy titled Using the Care Plan, revealed .It is the policy of the facility that the care plan be used in developing the resident's daily care routines.Daily care and documentation should be consistent with the resident's care plan . 2. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Dysphagia, Need for Assistance with Personal Care, Diabetes, Abnormal Weight Loss, and Congestive Heart Failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment and required total assistance with eating. Review of the care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-14 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 policy review, medical record review, and interview, the facility failed to conduct a care plan conference with the family representative for 1 of 7 (Resident #8) sampled residents reviewed. The findings include: The facility policy titled, Resident/Family Participation, dated 12/12/2017, revealed .It is the policy of this facility that each resident and his-her family members be encouraged to participate in the development of the resident's comprehensive assessment and care plan .Resident's representative are invited to attend and participate in the resident's assessment and care planning conference . Review of medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Dementia, Diabetes, Hypertension, and Chronic Obstructive Pulmonary Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Statue (BIMS) score of 4, which indicated Resident #8 was severely cognitively impaired. Review of the Care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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, observation, and interview the facility failed to provide care and services to assess, treat and prevent the spread of infection for 1 of 2 (Resident #36) sampled residents reviewed for pressure ulcers. The findings include: 1. Review of the facility policy titled, Handwashing/Hand Hygiene, revised June 2010 .This facility considers hand hygiene the primary means to prevent the spread of infections.All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.Resident, family members and/or visitors will be encouraged to practice hand hygiene.Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions.Before and after changing a dressing.If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations.before 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.
Show the remaining 18 citations
- Potential for harm · Dcited before2025-08-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to provide an environment free of accident hazards when nursing staff left a razor open and unattended on a bedside table for 1 of 35 (Resident #2) residents reviewed. The findings include: 1. Review of the facility policy titled, Sharps Disposal dated 8/2009, revealed .This facility shall discard contaminated sharps into designated containers.Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnosis including Cerebral Infarction (a condition where brain tissue dies due to lack of blood supply), Post-Traumatic Stress Disorder, Anxiety, Diabetes, Depression, and Seizures. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated that Resident #2 was cognitively…
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.
- Potential for harm · D2025-08-14 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, Centers for Medicare and Medicaid (CMS) Payroll-Based Journal (PBJ) Staffing Data Report, employee timesheet review, and interview the facility failed to ensure sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident during the 2nd quarter (1/1/2025-3/31/2025) for 8 of 26 days reviewed. The facility census upon entrance was 35. The findings include: 1. Review of the facility policy titled, Staffing, dated 10/2017, revealed .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services.Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. 2. Review of the CMS 2nd Quarter 2025 PBJ Staffing Data…
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.
- Potential for harm · Dcited before2025-08-14 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, Pharmacy Executive Summary review, observation, and interview, the facility failed to ensure medications were properly stored and secured when refrigerated medications were stored outside of the recommended temperature range for 1 of 1 medication refrigerator observed, when 2 nurses (Licensed Practical Nurse (LPN) A and LPN E) left medications unattended in 1 of 1 medication room, and when one of two (B Hall Medication Cart) medication carts was left unsecured and unattended. The findings include: 1. Review of the facility policy titled, Medication Labeling and Storage, revised 2/2023, 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.Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, trays or carts used to transport such items are not left unattended if open or otherwise potentially available to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-14 · tag F0949 — failed to train staff on dementia and abuse — isolatedProvide behavior health training consistent with the requirements and as determined by a facility 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 provide Behavioral Health Training to staff caring for 3 of 3 (Resident #8, #25, and #30) sampled residents reviewed for Dementia. The findings include: 1. Review of medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Dementia, Diabetes, Hypertension, and Chronic Obstructive Pulmonary Disease. Review of the quarterly MDS assessment dated [DATE], revealed a Brief Interview for Mental Statue (BIMS) score of 4, which indicated Resident #8 was severely cognitively impaired. 2. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Dementia, Unspecified Mood (Affective) Disorder, Diabetes, and Epilepsy. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #25 was severely cognitively impaired. 3. Review of the medical record revealed Resident #30 was admitted to the facility 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.
- Potential for harm · Ecited before2024-06-12 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, and interview, the facility failed to ensure medications were properly and securely stored when medications were left in residents' rooms for 4 of 34 (Resident #9, #19, #28, and #30 ) sampled residents, and 1 of 4 medication storage areas were left unlocked and unattended by (Licensed Practical Nurse (LPN) B), and when opened, undated, and expired medications were noted in 1 of 1 medication storage rooms. The findings include: 1. Review of the facility's policy titled, Self-Administration of Medications dated 11/18/2016 revealed .self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be clinically appropriate for the resident .Prescription medication of the residents permitted to self-administer are stored in central medication cart or medication room .The nurse then records such self-administration on the MAR [Medication Administration Record] . Review of the facility's policy titled, Administering…
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.
- Potential for harm · Ecited before2024-06-12 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, observation, and interview, the facility failed to ensure that food was prepared, and served under sanitary conditions when the oven door had a brown dried liquid on the glass, on the top of the oven door, carbon build up on the frying pans, a rusted mesh skimmer, steam table pans wet nesting on top of other table pans, and top of the convection oven and doors had a shiny film. The facility had a census of 34 with 34 of those residents receiving a meal tray from the kitchen. The findings include: 1. Review of the facility's policy titled, CLEANING SCHEDULES, dated 8/31/2018, revealed .The Food and Nutrition services staff shall maintain the sanitation of the Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinically qualified nutrition professional . 2. During an observation on 6/10/2024 at 8:35 AM, revealed the oven had dried brown liquid on the inside and top of the door. During an observation on 6/10/2024 at 8:40 AM,…
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.
- Potential for harm · Ecited before2024-06-12 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation and interview, revealed the facility failed to ensure infection control practices were followed for 2 of 6 sampled residents (Resident #9 and #27) during medication administration when 2 of 5 nurses Licensed Practical Nurse (LPN) D and Registered Nurse (RN) C) failed to perform hand hygiene during administration of medications, and when RN C failed to sanitize reusable equipment after exiting a residents room with enhanced barrier precautions. The findings include: 1. Review of the facility's policy titled, Administering Medications dated 4/2019, revealed . Staff follows established infection control procedures for the administration of medication as applicable . Review of the facility's policy titled, Handwashing/Hand Hygiene dated 8/2019, revealed .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections .Wash hands .after contact with a resident .Use an alcohol based hand rub .before and after direct contact with residents…
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.
- Potential for harm · D2024-06-12 · tag F0641 — isolatedEnsure 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 policy review, medical record review, observation and interview, the facility failed to accurately assess residents with wandering for 1 of 12 residents (Resident #32) reviewed for accuracy of assessments. The findings include: 1. Review of the facility's policy titled, Elopement/Unsafe Wandering Plan dated 2/7/2012 revealed, .Wandering is a random or repetitive locomotion. This movement may be goal directed or may be non goal directed or aimless .residents shall be evaluated for unsafe wandering or elopement potential during each care planning review . 2. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE], with diagnoses including Cognitive, Social, or Emotional Deficit following Cerebrovascular Disease, Vascular Dementia Severe with Agitation, Diabetes, Chronic Kidney Disease, and Alzheimer's Disease. Review of the Care Plan dated 5/1/2024, revealed Resident #32 was an Elopement risk/wanderer and wandered aimlessly. Review of the quarterly Minimum Data Set (MDS)…
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.
- Potential for harm · D2024-03-07 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to ensure foot care/treatment provided for high risk residents was appropriate for 1 of 5 (Resident #5) sampled residents reviewed. The findings include: 1. Review of the FOOT CARE policy dated August 25, 2014 revealed, .Toenails are to be clipped and filed smoothly .THE PODIATRIST OR REGISTERED NURSE IS TO CLIP NAILS FOR ALL DIABETIC RESIDENTS AND RESIDENTS WITH PERIPHERALVASCULAR DISEASE . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses of Diabetes, Hemiplegia and Hemiparesis Following Cerebrovascular Disease, Occlusion and Stenosis of Right Carotid Artery, Pressure Ulcer Sacral Stage 3, Atherosclerosis of Native Arteries of Right Leg with Ulceration of Heel and Midfoot, Aphasia, Peripheral Vascular Disease, Coronary Artery Disease, Vascular Dementia, Dysphagia, and Significant Stenosis of Right and Left lower extremity. Review of the Care Plan revealed, .2/10/2016 .I…
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.
- Potential for harm · D2024-03-07 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 policy review, medical record review, and interview, the facility failed to maintain an accurate medical record related to medication administration for 1 of 4 (Resident #9) sampled residents reviewed for medications. The findings include: 1. Review of the facility's policy titled, MEDICATION ADMINISTRATION . dated 8/25/2014 revealed, .Medications are administered as prescribed in accordance with good nursing principles and practices .Documentation .The individual who administers the medication dose records the administration on the resident's MAR [Medication Administration Record] directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure .administered and documented . 2. Review of the medical records revealed, Resident #9 was admitted to the facility on [DATE], with diagnoses of Acquired Absence of Left Leg Below Knee, Diabetes, Atherosclerotic Heart Disease and Hypertension. Review of the December 2023 Physician…
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.
- Potential for harm · D2023-03-23 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review and interview, the facility failed to ensure 1 of 14 sampled residents (Resident #20) or their families were invited to participate in planning their care. The findings include: Review of the facility's undated policy titled, Resident/Family Participation, revealed .It is the policy of this facility that each resident and his-her family members be encouraged to participate in the development of the resident's comprehensive assessment and care plan .Resident or Resident's representative are invited to attend and participate in the resident's assessment and care planning conferences . Review of the facility's policy titled, Quarterly Reviews, dated June 1, 2000, revealed .It is the policy of this facility that each resident's care plan be reviewed at least quarterly . Review of the facility's policy titled, Resident Assessment, dated June 1, 2000, revealed .Residents and/or their representative (sponsors) will be encouraged to participate in the initial, quarterly, 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.
- Potential for harm · D2023-03-23 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident personal funds accounts review, policy review, medical record review, and interview, the facility failed to notify the family and/or resident when the amount in the resident's account exceeded the eligibility limit for 8 of 19 residents (Resident #2, #3 #4, #6, #7, #11, #12, and #21) personal fund account statements reviewed and failed to refund the residents' funds within 30 days of death or discharge for 2 of 3 sampled residents (Resident #232 and #233) reviewed for trust funds. The findings include: 1. Review of the facility's Business Office Guidelines, revealed .The facility must notify each resident receiving medical assistance .when the amount in the resident's account reaches $200 less than the SSI [Social Security Income] resource limit .The notice must include that fact that if the amount in the account, is addition to the value of the resident's other nonexempt resources, reaches the applicable resources limits, the resident may loose eligibility for Medicaid or SSI .Upon death or…
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.
- Potential for harm · D2023-03-23 · tag F0606 — failed to not employ staff found guilty of abuse — isolatedNot hire anyone with a finding of abuse, neglect, exploitation, or theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, personnel file review, Employee Time Card review, and interview, the facility failed to ensure the abuse registry screening, criminal background screening, and reference checks were completed for 4 or 5 sampled employees (Social Services, the Wound Care/Registered Nurse (RN), Dietary Aide #1, and the Business Office Manager (BOM)) prior to hire. The findings include: Review of the facility's policy titled, Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Education, dated 8/23/2017, revealed The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardian, friends or other individuals . Review of the facility's policy titled, Hiring, revised 12/13/2017, revealed .The applicant should be checked with the Abuse Registry and for proper certification and/or license. This should be signed and dated as checked in the space…
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.
- Potential for harm · D2023-03-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation and interview the facility failed to ensure Physicians' Orders were followed for medication administration for 1 of 5 sampled residents (Resident #23) reviewed for unnecessary medication and 1 of 2 sampled residents (Resident #27) observed for medication administration through a Percutaneous Endoscopic Gastrostomy (PEG) Tube. The findings include: Review of the facility's policy titled, Physician's Orders, dated April 13, 2021, revealed .It is the policy of this facility that residents [residents'] medication and treatments are ordered by a licensed physician or other licensed health care professional as permitted by law. Physicians orders are carried out unless the nurse or other licensed personnel believe the order to be in accurate [inaccurate], non efficacious, or contraindicated . Review of the facility's policy titled, Enteral Tube Medication Administration, dated August 9, 2013, revealed .To safely and accurately administer oral medications…
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.
- Potential for harm · D2023-03-23 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to follow Physicians' Orders for Percutaneous Endoscopic Gastrostomy (PEG) tube for 1 of 2 sampled residents (Resident #5) reviewed for enteral feedings. The findings include: Review of the facility's policy titled, Physician's Order, dated April 13, 2021, revealed .Physician's orders are carried out unless the nurse or other licensed personnel believe the order to be in accurate [inaccurate] .contraindicated . Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Dysphagia, Alzheimer's Disease, Aphasia, Gastrostomy, and Adult Failure to Thrive. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 00, indicating he was severely impaired, and received enteral feedings. Review of the Physician's Orders dated 12/1/2022, revealed .Cleanse peg tube site every shift with soap and water…
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.
- Potential for harm · Dcited before2023-03-23 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, facility documentation review, observation, and interview, the facility failed to update and post the Daily Nursing Staff Postings for 9 of 40 (2/27/2023, 2/28/2023, 3/6/2023, 3/7/2023, 3/8/2023, 3/9/2023, 3/10/2023, 3/11/2023, and 3/12/203) days reviewed. The findings include: Review of the facility policy titled, Posting of Nursing Staffing, dated January 7, 2003, revealed .It is the policy of this facility to meet the CMS [Centers for Medicare & Medicaid Services] requirements for posting of nursing staffing .Daily each shift, the facility post the number of licensed and unlicensed nursing staff directly responsible for resident care. This information will be prominently displayed where residents, staff and the public may view it .numbers of licensed and unlicensed nurses for each shift will be posted daily on each shift .Licensed and unlicensed include [Register Nurse] RN's, [Licensed Practical Nurse] LPNs, and [Certified Nursing Assistant] CNAs .every nursing staff directly responsible for resident care . Review of the Nursing Staff Postings dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-23 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation and interview the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 2 staff members (Licensed Practical Nurse (LPN) #2) failed to perform hand hygiene during Percutaneous Endoscopic Gastrostomy (PEG) tube site care and failed to have a program in place to monitor for and prevent the growth of Legionella Disease and other opportunistic pathogens in the water system. The findings include: 1. Review of the facility's policy titled, Hand washing/Hand Hygiene, dated March 17, 2028, revealed .Hand washing Employees must wash their hands for at least 20 seconds using antimicrobial or non-antimicrobial soap and water .After handling items potentially contaminated with blood, body fluids, or secretions .Hand Hygiene with alcohol based hand rub .After handling used dressings . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Nontraumatic Subarachnoid…
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.
- Potential for harm · D2023-03-23 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of staff in-services and interview the facility failed to ensure the mandatory annual 12 hours of Certified Nursing Assistant (CNA) in-service training hours were completed for 3 of 3 sampled CNA's (CNA #3, #4, and #5) reviewed for in-servicing. The findings include: Review of a list of CNA staff provided by the facility revealed CNA #3 was hired on 8/28/2017, CNA #4 was hired on 3/1/2021, and CNA #5 was hired on 8/10/2021. The facility was unable to provide documentation of 12 hours of required in-service training for CNA's #3, #4, and #5 for the past 12 months. During an interview on 3/14/2023 at 8:17 AM, the Administrator stated, We do not have a Staff Development Coordinator .I can say we don't have it.
“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.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$43,644 in federal fines across 2 penalties.
- $26,299 — penalty dated 2025-08-14
- $17,345 — penalty dated 2025-05-01
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 COMMUNITY ELDERCARE SERVICES — 17 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.0 | -1.0 vs chain |
| Health inspection | 1 of 5 | 2.3 | -1.3 vs chain |
| Staffing | 1 of 5 | 3.2 | -2.2 vs chain |
| Quality measures | 2 of 5 | 1.8 | +0.2 vs chain |
The other 16 homes this chain runs (chain average 2.0★, per CMS)
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
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| COMMUNITY ELDERCARE SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2026 |
| ASLAM, TANVEER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2023 |
| EDWARDS, BETTY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/16/2025 |
| WRIGHT, DOUGLAS | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2000 |
| COMMUNITY LIVING CENTERS, LLC | Organization | ADP OF THE SNF | since 01/01/2026 |
CMS files one row per role, so the 8 rows in the source record cover these 5 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.
2 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 85% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $716K paid to related parties — landlords or management companies under common ownership — equal to about 19% 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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Tennessee Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 445354. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.