No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Reelfoot Manor Health And Rehab

1034 Reelfoot Drive, Tiptonville, TN 38079 · For profit - Limited Liability company · 116 certified beds · (731) 253-6681 Medicare & Medicaid certified

Call the home — (731) 253-6681 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jun 2026Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)
  • its last standard health inspection was over 4 years ago — the star rating may not reflect current conditions

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
215 S Court St · (731) 253-6690 · Call to confirm hours
Pharmacy
650 Carl Perkins Pkwy · (731) 253-0153 · Call to confirm hours
Grocery
Food Rite<0.1 mi
790 Everett St · (731) 253-7338 · Call to confirm hours
Park
1799 Vaughn Dr · Typically dawn to dusk
Place of worship

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 1 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 1 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.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased22.5%14.0%15.4%worse
Long-stay residents who lose too much weight3.0%6.1%5.4%better
Long-stay residents with a catheter left in their bladder1.6%0.7%0.9%worse
Long-stay residents with a urinary tract infection4.2%1.8%2.0%worse
Long-stay residents with depressive symptoms0.7%13.8%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.5%3.4%3.3%typical
Long-stay residents whose ability to walk worsened26.5%17.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication29.6%31.7%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.5%95.3%typical
Long-stay residents with pressure ulcers10.0%5.0%4.7%worse
Long-stay residents with worsening bladder/bowel control30.8%20.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table35.2%16.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.7%1.4%better
Short-stay residents rehospitalized after admission23.4%22.6%22.6%typical
Short-stay residents with an outpatient ER visit25.9%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.101.671.67worse
Long-stay outpatient ER visits per 1,000 resident days3.661.561.80worse

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.

10.8%U.S. median 10.7%
Went back to hospital
25.0%U.S. median 56.6%
Met the expected recovery
0.25U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy

Met the expected recovery: 25.0% 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 28 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 0.25 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot 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 SNF10.8%CMS range 7.3–15.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge25.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge17.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge25.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified10.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened12.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.7%CMS range 3.8–11.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.221.02Oct 2022–Sep 2024CMS makes no comparison for this 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

0.55
RN hours/ resident / day
1.11
LPN hours/ resident / day
1.92
Aide hours/ resident / day
3.58
Total nurse hours/ resident / day
0.36
RN hoursweekends
42.5%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 116 beds and averages 40.6 residents a day — about 35% occupied, or roughly 75 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.549 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.92 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 3.16 hrs/resident/day on weekends vs 3.75 on weekdays — 16% thinner on weekends. RN hours go from 0.62 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% 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

14
deficiencies at the latest standard inspection (2022-05-19)
2
at the previous standard inspection (2020-01-15)

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.

This trend is not current. The most recent of these two inspections was over 4 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

ABCDEFGHIJKL

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 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · G2022-05-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to implement appropriate interventions to prevent falls, failed to assess residents at risk for falls, and failed to assess residents after each fall for 6 of 6 sampled residents (Resident #15, #7, #22, #29, #39, and #48) reviewed for falls; the facility failed to ensure a safe environment when disposable razors were found in 1 of 36 resident bathrooms (Resident #39's room); and when 3 of 3 sampled residents (Resident #7, #39, and #41) were not using smoking aprons when smoking. The facility's failure to provide and implement appropriate interventions resulted in harm when Resident #15 sustained two falls which resulted in a laceration to the middle of the forehead, multiple skin tears, and a hematoma (bleeding outside the blood vessel) on the left side of the forehead. The findings include: Review of the facility's policy titled, Falls and Fall Risk, Managing, dated 5/2021, revealed .Based on previous evaluations and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-04 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, Intake Status Report form review, medical record review, and interview, the facility failed to perform a complete and thorough investigation for resident-to-resident altercations for 2 of 15 (Resident #55 and #56) sampled residents reviewed for abuse. The findings include: 1. Review of the undated facility policy titled Abuse, Neglect and Exploitation, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Abuse means the willful infliction of injury .resulting physical harm, pain or mental anguish .which can include .resident to resident altercations .Investigation of Alleged Abuse .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect .Written procedures for investigation include .identifying staff responsible…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Ecited before2022-05-19 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when medications were found unattended and unsecured in 2 of 36 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]), when 1 of 5 nurses (Licensed Practical Nurse (LPN) #4) left medications unattended and unsecured on top of the medication cart, and when 2 of 3 medication carts (C Hall Medication Cart and D Hall Medication Cart) were left unlocked and unattended during medication administration. The findings include: Review of the facility's policy titled, Storage of Medications, revised 4/2007, revealed .The facility shall store all drugs and biologicals in a safe, secure .manner .The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a .safe .manner .Only persons authorized to prepare and administer medications shall have access . Observation in room [ROOM NUMBER] on 5/16/2022 at 10:04 AM and 11:04 AM, revealed one container of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-19 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 maintain or enhance residents' dignity and respect when 2 of 9 staff members (Certified Nursing Assistant (CNA) #6 and #7) failed to use courtesy titles for 3 of 43 residents (Resident #1, #6, and #32) observed during dining, and when a catheter bag was not concealed in a privacy bag for 1 of 1 sampled resident (Resident #42) reviewed for an indwelling catheter. The findings include: Review of the facility's policy titled, Respect and Dignity; Right to Personal Property, dated 5/2021, revealed .Residents have the right to be treated with respect and dignity . Review of the facility's policy titled, Indwelling Urinary Catheters, dated 5/2021, revealed .Cover the urine bag to provide privacy . Dining observation on the 400 Hall on 5/16/2022 at 11:45 AM, revealed CNA #6 delivered Resident #1's meal tray. CNA #6 stated, Hey momma . Dining observation on the 400 Hall on 5/16/2022 at 11:47 AM, revealed CNA #6 delivered…

    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 · D2022-05-19 · 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

    Based on policy review, observation, and interview, the facility failed to ensure the environment was clean, comfortable, and sanitary when wheelchairs were in disrepair and covered with dried food particles, smears, and an unknown liquid for 2 of 10 resident wheelchairs (Resident #15 and #48) observed. The findings include: Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment ., dated 5/2021, revealed .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected . Observation in Resident #15's room on 5/16/2022 at 10:22 AM, revealed Resident #15's wheelchair had dried brown stains covering the sides of the cushion of the wheelchair. Observation in the Dining Room on 5/16/2022 at 3:08 PM, revealed Resident #15 seated in his wheelchair that had brown stains covering the sides of the cushion of the wheelchair. Observation in the Common Area on 5/17/2022 at 9:01 AM and 3:15 PM, and on 5/17/2022 at 9:05 AM and 4:28 PM, revealed Resident #48 seated in a wheelchair that had dried food…

    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 before2022-05-19 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility investigation, policy review, medical record review, observation, and interview, the facility failed to timely and thoroughly investigate an incident of resident-to-resident abuse for 2 of 9 sampled residents (Resident #17 and #27) reviewed. The findings include: Review of the facility's policy titled, Abuse Investigations, revised 11/2017, revealed .Reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management .The individual conducting the investigation will, as a minimum .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident . Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses of Dementia, Diabetes, Chronic Kidney Disease, Hypertension, and Hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #17 had severely impaired cognition, had disorganized…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-19 · 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 medical record review, observation, and interview, the facility failed to ensure the Care Plan was implemented and followed for Activities of Daily Living (ADL) for 1 of 1 sampled resident (Resident #48) reviewed. The findings include: Review of the medical record, revealed Resident #48 was admitted to the facility on [DATE] with diagnoses of Hemiplegia, Hemiparesis, Parkinsonism, Peripheral Vascular Disease, Alzheimer's Disease, Dysphagia, Schizophrenia, Cerebral Infarction, Hypertension, Depression, and Anemia. Review of the Care Plan dated 4/12/2022, revealed .The resident has an ADL Self Care Performance Deficit r/t [related to] CVA [Cerebral Vascular Accident] with hemiparesis .Interventions .Keep nails clean and trimmed . Review of the quarterly Minimum data Set (MDS) dated [DATE], revealed Resident #48 had moderately impaired cognition and required extensive assistance from staff for personal hygiene. Observation in the Common Area on 5/16/2022 at 3:15 PM, 5/17/2022 at 9:01 AM and 4:28 PM, and 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-19 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    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 the completion of a Discharge Summary with a recapitulation of the resident's stay and a transfer form at the time of discharge for 1 of 1 sampled residents (Resident #50) reviewed. The findings include: Review of the facility's policy titled, Discharge Summary and Plan, dated 5/2021, revealed .When the facility anticipates a resident's discharge to a private residence, another nursing care facility, a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment . Review of the medical record, revealed Resident #50 was admitted to the facility on [DATE] with diagnoses of Schizophrenia, Cerebral Infraction, Diabetes, Osteoarthritis, Chronic Obstructive Pulmonary Disease, Depression and Neuropathy. Review of the Progress Note dated 2/15/2022, revealed .Resident [Resident #50] discharged to .[Named Facility] via transportation van . The facility…

    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 · D2022-05-19 · 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 medical record review and interview, the facility failed to ensure medications were administered for 1 of 5 sampled residents (Resident #8) reviewed and failed to implement treatment orders following an injury for 1 of 6 sampled residents (Resident #48) reviewed. The findings include: Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Coronary Artery Disease, Anxiety, Seizures, and Unstageable Pressure Ulcer Sacral Region. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated Resident #8 was severely cognitively impaired and received antipsychotic and antidepressant medications. Review of the facility's Medication Administration Record (MAR) dated 3/2022, 4/2022, and 5/2022, revealed an order for Buspirone (a medication to treat anxiety and depression) 15 milligrams (MG) by mouth three times a day. The MARS revealed missed…

    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 · D2022-05-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 appropriate urinary catheter care and failed to provide a Physician's Order for an indwelling urinary catheter for 1 of 1 sampled resident (Resident #42) reviewed. The findings include: Review of the facility policy titled, Indwelling Urinary Catheters, dated 5/2021, revealed .Wash and dry your hands thoroughly .fill the wash basin .put on gloves .Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry .pour .water down the commode .place soiled linen into designated container .put on clean gloves .remove gloves and discard into the designated container. Wash and dry your hands .provide privacy .exposing the perineal area .With non-dominant hand separate the labia of the female resident .use a washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke .change the position of the washcloth and cleanse…

    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 · D2022-05-19 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services for a resident with enteral feedings when staff failed to ensure there was a Physician's Order for monitoring and cleaning a Percutaneous Endoscopic Gastrostomy (PEG) (a tube inserted into the stomach for the administration of nutrition and fluids) for 1 of 1 sampled resident (Resident #37) reviewed. The findings include: Review of the facility's policy titled Gastrostomy/Jejunostomy Site Care . dated 6/2021, revealed .The purpose of this procedure is to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection .Verify that there is a physician's order for this procedure . Review of the medical record, revealed Resident #37 was admitted to the facility on [DATE] with diagnoses of Pain, Depression, Anxiety, Hypertension, Convulsions, and Aphasia. Review of the medical record, revealed there was no Physician's Order for PEG site care and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2022-05-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to obtain Physician Orders for oxygen for 1 of 1 sampled resident (Resident #37) reviewed. The findings include: Review of the facility's policy titled, Oxygen Administration, revised 6/2021, revealed .Verify that there is a physician's order .After completing the oxygen setup .following information .recorded in .resident's medical record .date and time .name and title .who performed procedure .rate of oxygen flow, route .signature and title . Review of the medical record, revealed Resident #37 was admitted to the facility on [DATE] with diagnoses of Pain, Depression, Anxiety, Hypertension, and Seizures. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #37 used oxygen. Review of the Order Summary Report dated 5/3/2022, revealed there was no Physician's Order for Resident #37's oxygen, oxygen care, and maintenance. Observation in the resident's room on 5/16/2022 at 10:39 AM and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 side effects of antipsychotic medications were monitored for 1 of 5 sampled residents (Resident #39) reviewed for unnecessary medications. The findings include: Review of the facility's policy titled, Behavior Assessment and Monitoring, revised 2/2014, revealed .The IDT [Interdisciplinary Team] will monitor for side effects and complications .lethargy, abnormal involuntary movements, anorexia, and recurrent falling . Review of the medical record, revealed Resident #39 was admitted to the facility on [DATE] with diagnoses of Depression, Anxiety, Convulsions, and Mood Disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS assessment dated 5/3 /2022, revealed Resident #39 received an antipsychotic medication 7 days of the review period and received it on a routine basis. Review of the Order Summary Report dated 5/3/2022, revealed .OLANZapine [an antipsychotic medication] .15 MG…

    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 · D2022-05-19 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    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 a Physician's Order was obtained to provide Hospice services for 1 of 1 sampled resident (Resident #42) reviewed. The findings include: Review of the facility's policy titled, Physician's Services, dated 5/2021, revealed .The medical care of each resident is under the supervision of a Licensed Physician. Orders for the resident's immediate care and needs will be provided by a physician, physician assistant, nurse practitioner, or clinical nurse specialist . Review of the facility's policy titled, Hospice Program, dated 6/2021, revealed .Obtain a physician's order for Hospice services including diagnosis . Review of the medical record, revealed Resident #42 was admitted to the facility on [DATE] with diagnoses of Diabetes, Alzheimer's Disease, Dysphagia, and Hypertension. Review of the Care Plan dated 5/2/2022, revealed Resident #42 was receiving Hospice services. Review of the medical record, revealed there was not a…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-19 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to provide a functioning call light for 1 of 31 sampled residents (Resident #22). The findings include: Observation in the resident's room on 5/16/2022 at 7:49 AM, 9:02 AM, and 3:46 PM, and on 5/18/2022 at 11:21 AM and 12:33 PM, revealed Resident #22 did not have a call light available to call for assistance. During an interview on 5/18/2022 at 8:50 AM, the Assistant Director of Nursing (ADON) confirmed Resident #22 did not have a call light. He confirmed she should have a call light in her room.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-15 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on policy review, observation, and interview, the facility failed to ensure medications were securely locked and inaccessible in 1 of 5 medication storage areas (C-D Hall). The findings include: The facility policy titled, Storage of Medication, dated 4/2007 documented, .store all drugs and biologicals in a safe, secure .manner. Observation at the C-D Hall medication storage room on 1/13/2020 at 11:00 AM and 11:50 AM, showed the medication storage room was unsecure, without a door knob or a lock on the door. During an interview conducted on 1/13/2020 at 2:56 PM, the Director of Nursing (DON) was asked should the medication room be unsecure with medications inside. The DON stated, No.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-15 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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

    Based on policy review, medical record review, observation, and interview, the facility failed ensure documentation was complete and accurate for enteral tube feeding residuals for 1 of 4 sampled residents (Resident #55) reviewed for enteral tube feedings. The findings include: The facility's policy titled, Administering Medications through an Enteral Tube, dated 2/2018, documented, .The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube .For .gastrostomy tubes, check placement and gastric contents .If there is more than 100 ml [milliliters] of stomach content, withhold medication and notify the physician . Review of the medical record, showed Resident #55 had diagnoses of Pneumonitis, Gastrointestinal Hemorrhage, Dysphagia, Hemiplegia and Hemiparesis, Malnutrition, Adult Failure to Thrive, Gastrostomy Status, and Diabetes. Review of the Physician's Orders dated 1/2/2020, showed an order to administer Osmolite 1.2 at 60 ml [milliliters] / [per] hr [hour] x [times] 24 hours/day .Contact RD [Registered Dietician] if…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-03-06 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 maintain or enhance resident dignity and respect for Resident #1 and #63 when of 1 of 1 (Assistant Director of Nursing (ADON)) staff members failed to knock before entering the residents' room and 3 of 3 (ADON, Licensed Practical Nurse (LPN) #4, and Certified Nursing Assistant (CNA) #1) staff members failed to provide privacy during wound care for Resident #46. The findings include: 1. The facility's Exercise of Rights / Resident Rights policy revised November 2017 documented, .8. Residents' private space and property shall be respected at all times .Staff will knock and request permission before entering residents' rooms .12. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during .treatment procedures . 2. Observation in Resident #1's room on 3/5/19 at 2:09 PM, the ADON entered Resident #1's room without knocking, and failed to respect the resident's private space. Observation in Resident #63's room…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-03-06 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure an assessment was accurate related to Pre-admission Screening and Resident Review (PASRR) for 6 (Resident #24, 28, 34, 47, 53, 55) sampled residents reviewed of the 24 residents included in the stage 2 review. The findings include: 1. Medical record review revealed Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Diabetes Mellitus, Metabolic Encephalopathy, Hypertension, Epilepsy, Anxiety, Depression, and Schizoaffective Disorder. The annual Minimum Data Set (MDS) dated [DATE] documented, .0. No .Conditions Related to ID/DD [intellectual disability/developmental disability] Status [indicated a level II PASRR had not been completed] . A Level II Outcome PASRR was completed 10/5/17 and the resident did not require active treatment. 2. Medical record review revealed Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Dysphagia, Tachycardia, Depression,…

    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 · E2019-03-06 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation and interview, the facility failed to ensure 2 of 2 staff members (Assistant Director of Nursing (ADON) and Licensed practical Nurse (LPN) #1)) performed hand hygiene to prevent the potential spread of infection during wound care and tracheostomy care and maintain infection control practices during wound care. The findings include: 1. The facility's Handwashing/Hand Hygiene policy, revised April 2010, documented, .This facility considers hand hygiene the primary means to prevent the spread of infection .5. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions .c. Before and after direct resident contact .k. Before and after changing a dressing .q. After contact with a resident's mucous membranes and body fluid or excretions .u. After removing gloves . The facility's Tracheostomy Care policy revised October 2010 documented, .6. Remove old dressings .7. Wash…

    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 · D2019-03-06 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure the physician was notified that medications had not been administered for 1 of 63 (Resident #37) observed on initial tour. The findings include: 1. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses of Epilepsy, Diabetes Mellitus, Hypertension, Gastroesophageal Reflux Disease, Dementia with Behavioral Disturbances, Benign Prostatic Hyperplasia, and Schizoaffective Disorder. The Physician order dated 2/28/19 documented, .Gabapentin [Neurontin ordered to relieve nerve pain/seizures] 400 mg [milligram] tablet .Give 2 tablet three times daily . The Medication Administration Record (MAR) dated March 2019 documented Resident #37's Gabapentin was administered at 6:00 AM. There was no documentation in the nurses notes dated 3/4/19 that Resident #37's physician had been notified the resident had not received the Gabapentin at 6:00 AM. 2. Observation in Resident #37's room…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-03-06 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, medical record review, and interview, the facility failed to report an allegation of abuse for 1 of 3 (Resident #52) residents reviewed for abuse allegations as evidenced by Certified Nursing Assistant (CNA) #2 and Licensed Practical Nurse (LPN) #5 not following facility policy to immediately report allegations of abuse to the Abuse Coordinator. The findings include: 1. The facility's Reporting Abuse to Facility Management policy revised 9/2012 documented, .4 .Employees must immediately report any suspected abuse or incident of abuse to their direct supervisor, Abuse Coordinator and/or Administrator .7 .The Administrator or Director of Nursing Services must be immediately notified of suspected abuse or incidents of abuse .8 .When an Incident of resident abuse is suspected .the incident must be immediately reported to the facility management . Interview with LPN #5 on 3/5/19 at 7:38 AM in the Conference Room, LPN #5 was asked what time Resident #52 reported the allegation of abuse. LPN #5 stated, .it was 6:00 AM in the morning [2/25/19] . LPN #5 was asked what…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-03-06 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, facility investigation review, and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 of 1 (Resident #52) residents reviewed for allegations of abuse. The findings include: 1. Review of the facility's Operational Policy and Procedure Manual .Abuse policy revised on 9/2012, documented, Abuse Investigations .4 .Witness reports will be obtained in writing. Witnesses will be required to sign and date such reports .Reporting Abuse to Facility Management .9 .Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident .Findings of the examination must be recorded in the resident's medical record .1 .written statements from witnesses .must be provided to the Administrator . 2. Review of the facility's Accident and Incidents-Investigating and Reporting policy revised on 4/2010 documented, .5 .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-03-06 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interview the facility failed to ensure the provision of a timely ophthalmologist consult for 1 of 2 (Resident #24) sampled residents reviewed for vision. The findings include: Medical record review for Resident #24 documented an admission date of 10/12/17 with diagnoses of Type 2 Diabetes, Metabolic Encephalopathy, Epilepsy, Anxiety, Major Depressive Disorder, and Schizoaffective Disorder. Interview with Resident #24 on 3/4/19 at 3:02 PM in the resident's room, Resident #24 was asked if she had seen the eye doctor about her cataract. Resident #26 stated .I have seen the eye doctor a couple of months ago and they said I needed glasses .I don't have any money to buy me any . The Eye Care Chart Note dated 1/17/19 documented .Cataracts are visually significant; Please schedule for cataract evaluation with Ophthalmologist of facility choice . Interview with the Social Service Director (SSD) on 3/05/19 at 10:50 AM, in the SSD office, the SSD was asked if Resident #24 had been seen by the optometrist. The SSD stated Yes and was recommended to have a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-03-06 · 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 policy review and interview, the facility failed to ensure the proper disposal of a controlled medication when 1 of 2 (Registered Nurse (RN) #1) disposed of a controlled medication in a garbage can. The findings include: 1. The facility's Discarding and Destroying Medications policy revised June 2012 documented, .Medications that cannot be returned to the dispensing pharmacy (e.g. [example], non unit-dose medications, medications refused by the resident, and/or medications left by residents upon discharge) shall be destroyed .by state regulations .2. Non-controlled and Schedule V [5] controlled drugs must be destroyed in the presence of two (2) licensed nurses or per state law . 2. Observations in Resident #37's room on 3/4/19 at 9:58 AM, revealed Registered Nurse (RN) #1 removed the tablet from the resident's shirt and disposed of the tablet in Resident #37's trash can. 3. Interview with the Director of Nursing (DON) on 3/5/19 at 7:52 AM, in the conference room, the DON was asked what should nurses do when a medication is refused or found to not have been taken, the DON…

    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 · D2019-03-06 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 GERIATRIC MEDICATION HANDBOOK, 11TH EDITION provided by the American Society of Consultant Pharmacists, policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 6 (Licensed Practical Nurse (LPN) #2 and #3) administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 26 opportunities, which resulted in an error rate of 7.69%. The findings include: 1. The GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists documented, .DIABETES: INJECTABLE MEDICATIONS .NovoLog .Insulin .Rapid-Acting Insulin .ONSET .15 min .ADMINISTRATION .5-10 minutes prior to meals .Novolog .Rapid-Acting Insulin .ONSET 15 min .5-10 minutes before meals . 2. The facility's Insulin Administration policy revised October 2010, documented, .provide guidelines for the safe administration of insulin to residents with diabetes .The three key characteristics of insulin are .how…

    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 · D2019-03-06 · 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 review of the GERIATRIC MEDICATION HANDBOOK, 11TH EDITION provided by the American Society of Consultant Pharmacists, policy review, medical record review, observation, and interview, the facility failed to ensure residents were free of significant medication errors when 2 of 6 (Licensed Practical Nurse (LPN) #2 and #3) nurses failed to administer food promptly after administration of a rapid-acting insulin. The findings include: 1. The GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists documented, .DIABETES: INJECTABLE MEDICATIONS .NovoLog .Insulin .Rapid-Acting Insulin .ONSET .15 min .ADMINISTRATION .5-10 minutes prior to meals .Novolog .Rapid-Acting Insulin .ONSET 15 min .5-10 minutes before meals . 2. The facility's Insulin Administration policy revised October 2010, documented, .provide guidelines for the safe administration of insulin to residents with diabetes .1. The three key characteristics of insulin are: a. Onset of action-how quickly 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-03-06 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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

    Based on policy review, medical record review, observation, and interview, the facility failed to ensure the medical record was accurate for medication administration for 1 of 19 (Resident #37) residents reviewed. The findings include: 1. The facility's Documentation Guidelines dated August 2008 documented, .3. Incidents, accidents, or changes in the resident's condition must be recorded . 2. A Physician order dated 2/28/19 for Resident #37 documented, .Gabapentin [Neurontin ordered to relieve nerve pain/seizures] 400 mg [milligram] tablet .Give 2 tablet three times daily . The Medication Administration Record (MAR) dated March 2019 documented Resident #37's Gabapentin was administered at 6:00 AM. 3. Observation in Resident #37's room during initial tour on 3/04/19 at 9:50 AM, revealed Resident #37 in bed and a white scored tablet stuck on his shirt in the right upper chest area. Observation in Resident #37's room on 3/4/19 at 9:58 AM, revealed Registered Nurse (RN) #1 removed the tablet from the resident's shirt and disposed of the tablet in Resident #37's trash can. 4. Interview…

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

    Resident Assessment and Care Planning 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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

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

$5.6M
Net patient revenuemost recent cost report
+1.3%
Operating marginrevenue minus expenses
$296K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 84%Medicare 11%Other / private 5%

About 84% 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 $296K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$281per resident / day
operating cost
$8,534per month
≈ monthly operating cost
$285per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Tennessee
$9,429/mo
Nursing home (semi-private)
$10,038/mo
Nursing home (private)
$5,845/mo
Assisted living

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 445285. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2022-05-19, 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.

What to do next