Ascension Living Alexian Village Tennessee

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.

47.2% 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 93 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 76.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 68 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.52 therapist hours per resident per day in 2026Q1 — more than 82% 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.

Staffing

How full it usually is: this home is certified for 114 beds and averages 89.1 residents a day — about 78% occupied, or roughly 25 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.25 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 3.75 hrs/resident/day on weekends vs 4.17 on weekdays — 10% thinner on weekends. RN hours go from 0.75 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% 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.

28 citations, most serious first. The 16 most serious are shown; the remaining 12 are one tap away and print in full.

• Immediate jeopardy · Jcited before2023-10-11 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of the Hospitalists Discharge Summary, and review of the facility's policy, the facility failed to revise the Comprehensive Care Plan with newly identified problem areas and with new interventions for one of 35 sampled residents (Resident (R) 7). On 07/30/23, R7 was transferred to the hospital after he was discovered entrapped between his mattress and a grab bar attached to his bed. When R7 was readmitted to the facility on [DATE], his care plan was not revised to include updated interventions related to his entrapment. Additionally, while being treated at the hospital for the entrapment incident, it was discovered that R7 had a fecal impaction. After receiving the Resident's hospital discharge summary upon the resident's readmission to the facility, the facility failed to revise the resident's care plan to include the newly identified bowel problem. The facility's failure to ensure R7's Comprehensive Care Plan was revised as indicated has caused or is likely to cause…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-10-11 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  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 observation, interview, record review, and review of a facility document, the facility failed to ensure services were provided to meet acceptable professional standards for six out of six sampled residents (Resident (R) 4, R7, R8, R20, R21, and R22) reviewed for accidents, bowel monitoring, and supplemental oxygen therapy, out of a total sample of 35. On 07/30/23, R7 was found entrapped between the grab bar and mattress and sustained multiple fractures to his ribs. The nurse on duty assigned to R7 failed to complete a thorough assessment of R7 and failed to accurately report the incident to the resident's physician. Additionally, the facility failed to ensure R7 received supplemental oxygen therapy per the physician orders. R7's Physician's Orders were for R7 to have oxygen administered at two liters per minute (lpm) to keep his saturations above 90% for hypoxia (low level of oxygen). On 09/26/23, R7's oxygen concentrator was not working properly. The resident's oxygen saturation dropped to 83%. The…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-10-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of the facility's policy, the facility failed to ensure six of six residents (Resident (R) 4, R7, R8, R20, R21, and R22) reviewed for bowel movement monitoring received the necessary care and treatment in accordance with professional standards of practice. On 07/30/23, R7 was transferred to the hospital after becoming entrapped in between his mattress and grab bar. While receiving treatment, it was discovered that R7 had a fecal impaction. Record review revealed there were no documented bowel movements for R7 for five days leading up to the fecal impaction diagnosis. Additional record reviews revealed the facility's systemic failure of ensuring residents' bowel movements were monitored to prevent constipation. The facility's systemic failure has the potential to affect all residents who resided at the facility. The facility's failure to ensure residents received quality of care and treatment has caused or is likely to cause serious injury, harm, impairment, 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-10-11 · 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 observations, interviews, record reviews, and review of the facility's policies, the facility failed to ensure residents were free from accidents and hazards for one of three resident (Resident (R) 7) reviewed for accidents out of a sample of 35. On 07/30/23, R7 was discovered entrapped between his low air loss mattress and the grab bar attached to his bed. The resident sustained multiple fractures to his right and left ribs. Additionally, the facility failed to complete a timely and thorough investigation into the incident. An Immediate Jeopardy was identified on 09/26/23 and was determined to exist starting on 07/30/23, in §483.25(d) F689: Accidents. The Administrator was notified on 09/26/23 at 3:45 PM of the failure to prevent accidents and hazards for R7. The facility was notified that an acceptable plan of removal had not been submitted and the Immediate Jeopardy was ongoing. Findings include: Review of R7's undated Profile Face Sheet, provided by the facility revealed the resident was admitted 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-10-11 · 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

  Based on interview, record review, and review of the facility's Administrator's and Director of Nursing's (DON) Job Descriptions, the facility failed to be administered in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident in the facility. During an abbreviated survey, five Immediate Jeopardies were identified, with the highest scope and severity (S/S) of a L and four standard level tags were cited with the highest S/S being an F. The facility failed in the areas of 42 CFR 483.10 Notification of Change (F580), 42 CFR 483.12 Free from Misappropriation (F602), 42 CFR 483.25 Quality of Care (F684), 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F657), 42 CFR 483.70 Resident Records-Identifiable Information (F842), 42 CFR 483.25 Bed Rails (F700), 42 CFR 483.25 Respiratory Care (F695), 42 CFR483.21 Comprehensive Care Plans/Services Meet Professional Standards of Quality (F658), and 42 CFR 483.25 Accidents (F689). The facility's failure to ensure it was administered in…

  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 · G2025-12-10 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, facility investigation review, and interviews, and corrective action plans, the facility failed to prevent significant medication errors for 1 (Resident #99) resident of 4 residents reviewed for medication administration. Registered Nurse (RN) M administered medications intended for another resident to Resident #99 in error. The medication error caused Resident #99 to develop severe hypotension (low blood pressure) resulting in hospitalization. The facility's failure to administer medications according to physician's orders resulted in HARM to Resident #99. The facility was cited at F-760 as Past Non-Compliance. No further corrective actions are required. Non-Compliance began 9/1/2025 and ended on 11/17/2025. The findings include:Review of the facility policy titled, Administering Medications, dated 12/2024, revealed .Medications shall be administered in accordance with orders .per best practice/regulatory guidelines .The individual 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.

  Pharmacy Service Deficiencies · Past Non-Compliance
• Potential for harm · D2025-12-10 · tag F0557 — isolated
  Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
  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 review of facility policy, observation and interviews, the facility failed to ensure staff promoted resident dignity during dining for 1 resident (Resident #26) of 7 residents observed during dining.The findings Include:Review of the facility's undated policy titled, Tennessee Notices .Nursing Home Resident Rights, revealed .you [the resident] have the right to a dignified existence .a facility environment must treat each resident with respect and dignity and care for each resident in a manner .that promotes maintenance or enhancement of his or her quality of life .Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including History of Stroke with Hemiplegia, Aphasia, and Atrial Fibrillation.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #26 had severely impaired cognitive skills for daily decision making, and required substantial/maximal assistance with eating. During an observation on 12/8/2025 at 12:20 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-10 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, review of the medical record, observation, and interview, the facility failed to ensure call lights were within reach for 1 resident (Resident #41) of 18 residents reviewed on the 800-west hallway. The findings include:Review of the facility policy titled, Procedure: Answering the Call Light, dated 1/2024, revealed .The purpose of this procedure is to respond to the resident's requests and needs. The community [facility] should be adequately equipped to allow residents to call for assistance .when the resident is in bed .be sure the call light is within reach of the resident .Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including Anemia, Coronary Artery Disease, Hypertension, Parkinsons, and Depression.Review of the comprehensive care plan for Resident #41 dated 5/19/2025, revealed .[Resident #41] is at risk for impaired communication related to cognitive impairment .[Resident #41] will be able to communicate some…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-10 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's policy, review of the medical records, observations, and interviews, the facility failed to implement the comprehensive care plan for an orthotic device for 1 resident (Resident #12) and failed to update the care plan for refusal of splint use for 1 resident (Resident #39) of 5 residents reviewed for Activities of Daily Living (ADLs)/Mobility.The findings Include:Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease and Dysphagia.Review of the medical record revealed Resident #12 was transferred to the hospital on 9/11/2025, returned to the facility the same day with a new diagnosis of a fracture of the right distal fibula (bone in the lower leg toward the ankle), and the resident had a new physician's order for a tall walking boot at all times.Review of the comprehensive care plan for Resident #12 dated 9/12/2025, revealed, .resident to wear boot on her right leg at all times, can be removed during…

  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 · D2025-12-10 · 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 review of medical records and staff interview, the facility failed to ensure accurate documentation of a resident's meal intake which prevented the facility from determining whether the resident met the criteria for administering the ordered nutritional supplement for 1 resident (Resident #2) of 3 residents reviewed for nutrition.The findings Include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Specified Nutritional Anemia, Dysphagia, History of Subdural Hematoma, and Chronic Migraines.Review of the comprehensive care plan for Resident #2 dated 11/17/2025, revealed .at risk for unintended weight loss related to inadequate intake and dysphagia .provide nutritional supplements as ordered .Review of a Physician's Order for Resident #2 dated 11/20/2025, revealed .Give one container of Jevity [liquid nutrition supplement] if resident eats 50% or less at meals . to be administered three times daily.Review of a significant change in status…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-10 · tag F0725 — failed to have enough nursing staff — isolated
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, review of the facility assessment, review of a facility document, review of resident council minutes, review of the medical record, observations, and interviews, the facility failed to ensure sufficient nursing staff as determined by the acuity of the resident population on 1 of 4 hallways observed. The findings include:Review of the facility policy titled, Procedure: Answering the Call Light, dated 1/2024, revealed .The purpose of this procedure is to respond to the resident's requests and needs .Answer the resident's call light as soon as possible .Review of the facility assessment tool dated 6/16/2025, revealed .Staffing Plan .Staffing ratios and needs are based upon resident census, resident need, and facility acuity [the severity of a resident's illness or condition, indicating the intensity of care needed] .Staffing assignments are based on overall patient [resident] acuity per unit [hallway] .Assignments are .modified to reflect resident needs based on acuity…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-10 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on review of the facility policy, observation, and interviews, the facility failed to reconcile controlled medications for 3 residents (Residents #86, #13, and #67) of 8 residents reviewed for controlled substance reconciliation. The findings include: Review of the facility's policy titled, Medication Administration, dated 12/2025, revealed .if medication is a controlled substance .sign narcotic book . During an observation and interview beginning on 12/9/2025 at 7:15 AM of the 700 East Medication Cart revealed the following: Registered Nurse (RN) N was asked to review Resident #86's narcotic reconciliation sheet. Review of the Controlled Drug Record (narcotic reconciliation sheet) for Resident #86 revealed .oxyCODONE (opioid used to treat moderate to severe pain) 10/325 MG (Milligram) .Amount Left .8 . Review of Resident #86's narcotic card revealed a count of 7 tablets remaining. RN N was asked about the difference in the number and stated, .she [Resident #86] refused the dose earlier and it needs to be wasted with the supervisor .There are 7 in the package, not 8 .RN N was…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-10 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure proper infection control practices related to hand hygiene were followed during meal service when 1 staff member failed to offer hand hygiene assistance to 1 resident (Resident #24) of #24 residents observed during meal tray distribution on 1 of 4 hallways.The findings include:Review of the facility's policy titled, Hand Hygiene, revised 6/2025, revealed .Encouragement, remainders, and/or assistance with hand hygiene is provided to residents before meals .Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Need for assistance with personal care.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #24 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was severely cognitively impaired. Further review revealed the resident required supervision…

  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 · D2024-09-25 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  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, observations and interviews, the facility failed to provide a homelike environment for 2 residents (Resident #12 and Resident #7) of 83 residents reviewed for a homelike environment. The findings include: Review of the facility's policy titled, Quality of Life-Homelike Environment, dated 1/2024, revealed .the characteristics of the community that reflect a .homelike environment .these characteristics include .cleanliness and order . Medical record review revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Difficulty Walking and Neuromuscular Dysfunction of the Bladder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. During an observation in room [ROOM NUMBER], on 9/23/2024 at 2:45 PM, 2 pieces of blue tape, to the bottom trim…

  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 · D2024-09-25 · 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, observation and interview, the facility failed to develop Enhanced Barrier Precautions (EBP) on the comprehensive care plan for 3 residents (Residents #36, Resident #12 and Resident #24) of 21 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Care Plans-Comprehensive Person-Centered, dated 9/2023, revealed .the comprehensive, person-centered care plan will .describe the services that are the be furnished to attain or maintain the resident's .well-being .incorporate identified problem areas .reflect treatment .reflect currently recognized standards of practice for problem areas and conditions . Medical record review revealed Resident #36 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Functional Quadriplegia, Complete Lesion of Cervical Spine and Neurogenic Dysfunction of Bladder. Review of the Physician's Order for Resident #36 dated 9/3/2020, revealed .indwelling…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-09-25 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation and interview, the facility failed to implement Enhanced Barrier Precautions (EBP) for 3 residents (Residents #36, Resident #12, and Resident #24) of 7 residents reviewed for indwelling devices. The findings include: Review of the facility's policy titled, Enhanced Barrier Precautions in Skilled Nursing Communities, revised 3/2024, revealed .Enhanced Barrier Precautions .infection control intervention .that employs targeted gown and glove use .shall be implemented during high-contact resident care activities .with .indwelling medical devices .regardless of .infection or colonization .during .dressing .bathing . transferring .providing hygiene .changing linens .changing briefs . device care or use .urinary catheter . Medical record review revealed Resident #36 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Functional Quadriplegia, Complete Lesion of Cervical Spine and Neurogenic Dysfunction of Bladder.…

  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

“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

$226,846 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $12,438 — penalty dated 2025-12-08
• $214,408 — penalty dated 2023-10-11
• Medicare payment denial — starting 2023-11-10 for 63 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 ASCENSION LIVING — 12 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

CMS files one row per role, so the 14 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

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 $3.3M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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 2024. 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, FY2024). 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