Obion County Nursing Home
1084 East County Home Road, Union City, TN 38261 · Government - County · 56 certified beds · (731) 885-9065 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $23,963 in federal fines (most recent 2025-06-26)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 18.7% | 14.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.2% | 6.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.4% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 4.1% | 1.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.7% | 13.8% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.1% | 3.4% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 4.2% | 17.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 52.6% | 31.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.6% | 5.0% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 21.8% | 20.0% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.9% | 16.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 15.4% | 1.7% | 1.4% | worse |
| Short-stay residents rehospitalized after admission | 23.4% | 22.6% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.2% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.11 | 1.67 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.15 | 1.56 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
39.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 45 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 51.9% 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 27 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 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 39.6%CMS range 28.6–52.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 7.9–15.6 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 51.9% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 51.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 48.1% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.3%CMS range 4.9–16.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.42 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 56 beds and averages 44.0 residents a day — about 79% occupied, or roughly 12 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 3.78 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 3.21 hrs/resident/day on weekends vs 4.01 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.61 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 12 most serious are shown; the remaining 10 are one tap away and print in full.
- Immediate jeopardy · Kcited before2024-01-29 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Blood Glucose Monitoring User Guide, policy review, job description review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when multi-use blood glucose meters were not cleaned and disinfected to prevent cross-contamination of bloodborne pathogens for 4 of 14 sampled residents (Residents #3, #9, #38, and #49) reviewed for blood glucose monitoring. Observations revealed 4 of 6 nurses (Licensed Practical Nurses (LPN) #1, #2, #3, and #4) failed to disinfect the blood glucose meters after use on each Resident observed during blood glucose monitoring/medication administration. The facility failed to monitor the lint dryers for 2 of 2 (Dryer #1 and #2) dryers and failed to perform proper hand hygiene for 2 of 14 staff members (Certified Nursing Assistant (CNA) #1 and #8). The facility failed to ensure soiled linens were properly contained during transport down the hall and failed to monitor for an outbreak of bed…
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.
- Actual harm · Gcited before2025-06-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, facility video review, facility investigation review, observation, and interview, the facility failed to ensure staff followed the facility policy for a resident transfer and assessment of an injury after a transfer for 1 of 3 (Resident #1) sampled residents reviewed for accident hazards. On 6/11/2025, Resident #1, a cognitively impaired vulnerable resident, who required 2-person assistance with transfers, was transferred from the bed into the shower chair, and from the shower chair into the wheelchair, using her arms instead of the mechanical lift, by 2 Certified Nursing Assistants (CNA) A and B. Approximately 3 hours later, CNA B reported the injury to Licensed Practical Nurse (LPN) F, who was observed to assess Resident #1's injury on facility video footage, and failed to report the incident to Administration or document the assessment. The failure of the facility staff to transfer Resident #1 according to the facility policy resulted in actual Harm to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-20 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, Board of Examiners of Nursing Home Administrators (BENHA) review, facility benefit plan review, employee file review, employee W-2 form review, employee check stub review, timeclock punch detail review, bookkeeping system screenshot review, Certified Public Accounting (CPA) Firm documentation review, facility email review and interview, Administration failed to ensure appropriate checks and balances were implemented to prevent financial mismanagement of the payroll system and the facility checking account. Administration failed to ensure Medicare and Medicaid payments, insurance payments and private payments from residents, were protected from cash out by facility staff members when payroll, which was previously outsourced to another entity, was brought back into the facility on 1/1/2024. Three staff members (Administrator A, Social Worker (SW)/Bookkeeper #1 and Human Resources (HR)/Bookkeeper #2 cashed out thousands of dollars of vacation and holiday pay from 1/1/2024 through…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-20 · tag F0837 — isolatedEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, Board of Examiners of Nursing Home Administrators (BENHA) review, Governing Board/Body Meeting minutes review, Certified Public Accounting (CPA) Firm documentation review, and facility email review, the Governing Board/Body failed to provide oversight and implement appropriate checks and balances to prevent financial mismanagement of the payroll system and the facility bank account into which payments, including Medicare, Medicaid, insurance, and private payments from residents were deposited. The Governing Board/Body failed to appoint an Administrator who was held accountable to responsibly manage the facility and the payroll system and communicate all aspects of the facility's financial operations to the Governing Board/Body. The failure of the Governing Board/Body to provide oversight of the Administrator, the facility's payroll system and the facility's bank account had the potential to affect all residents in the facility. The facility's census was 45. The findings include: 1. Review of the facility policy titled, Governing Body, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-19 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to perform practices to prevent the potential spread of infections during medication administration and pressure ulcer care when 3 of 3 (Licensed Practical Nurse (LPN) A, B, and C) staff members failed to perform hand hygiene, administered contaminated medications and performed pressure ulcer care with contaminated gloves. The findings include: 1. Review of the undated facility policy titled, Hand Hygiene, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . Wet hands with water .Apply to hands the amount of soap recommended by the manufacturer .Rub hands together vigorously for at least 20 seconds .Rinse hands with water .Dry thoroughly with a single-use towel .Use clean towel to turn off the faucet . 2. Review of medical record revealed Resident #5 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.
- Potential for harm · D2025-03-19 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 residents were free of physical restraints for 1 of 1 (Resident #31) sampled residents reviewed for restraints. The findings include: 1. Review of the facility policy titled, Restraint Free Environment, dated 3/19/2025, revealed .Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement .Physical restraints may include .Using devices in conjunction with a chair .belts, that the resident cannot remove and prevents the resident from rising. 2. Review of the medical record review revealed Resident #31 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, Heart Failure, and Malignant Melanoma of Skin. Review of the Care Plan dated 2/20/2025, revealed .The resident is HIGH risk for falls r/t [related to] confusion…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the policy review, medical record review, observation, and interview, the facility failed to identify, evaluate and analyze the cause to eliminate the risk of accident hazards for 1 of 2 (Resident #12) sampled residents reviewed for accident hazards, when on 12/27/2024 Resident #12 fell from a lift device and sustained a fracture of the left humerus. The findings include: 1. Review of the facility's policy titled Accidents and Supervision, dated 1/16/2025, revealed .The resident environment will remain free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents .Identifying hazard(s) and risk(s) .Evaluating and analyzing hazard(s) and risk(s) .Implementing interventions to reduce hazard(s) and risk(s) .Monitoring for effectiveness and modifying interventions when necessary . 2. Review of the medical record revealed Resident #12 was readmitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Chronic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 care and services to maintain an indwelling urinary catheter when nursing staff failed to obtain a physician's order, and provide care and services for the indwelling urinary catheter for 1 of 3 (Resident #32) sampled residents reviewed for indwelling urinary catheters. The findings included: 1. Review of the facility policy titled Catheter Care, dated 11/21/2024, revealed It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care .Catheter care will be performed every shift and as needed by nursing personnel . 2. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE], with diagnoses including Pneumonia, Diabetes, Lymphedema, and Pressure Ulcer Stage 2. Review of the significant change Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15, which indicated Resident #32…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-19 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such 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 provide ongoing communication of care with the dialysis center and failed to assess and monitor the dialysis site for any redness, swelling and/or signs of infection for 1 of 1 (Resident #25) sampled residents reviewed for dialysis. The findings include: 1. Review of the facility's policy titled, Hemodialysis, dated 2/18/2025, revealed .The facility will provide necessary care and treatment, consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan .Licensed nurse will communicate to the dialysis facility .Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility .Physician/treatment orders, laboratory values, and vital signs .Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-19 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility documentation review, observation, and interview, the facility failed to ensure posted staffing information was accurate for 24 of 33 days (2/13/2025, 2/14/2025, 2/17/2025, 2/19/2025, 2/20/2025, 2/21/2025, 2/24/2025, 2/25/2025, 2/26/2025, 2/27/2025, 2/28/2025, 3/3/2025, 3/4/2025, 3/5/2025, 3/6/2025, 3/7/2025, 3/8/2025, 3/9/2025, 3/10/2025, 3/11/2025, 3/12/2025, 3/13/2025, 3/14/2025 and 3/19/2025) reviewed during the survey. The findings include: Review of the facility's Daily Staffing Posting dated 2/13/2025 through 3/14/2025, revealed no Registered Nurse (RN) hours for the following dates: 2/13/2025, 2/14/2025, 2/17/2025, 2/19/2025, 2/20/2025, 2/21/2025, 2/24/2025, 2/25/2025, 2/26/2025, 2/27/2025, 2/28/2025, 3/3/2025, 3/4/2025, 3/5/2025, 3/6/2025, 3/7/2025, 3/8/2025, 3/9/2025, 3/10/2025, 3/11/2025, 3/12/2025, 3/13/2025, 3/14/2025, and 3/19/2025. Observation in the hallway on 3/19/2025 at 9:00 AM, revealed the Daily Staffing Posting dated 3/19/2025 was hanging on the wall outside of the nurse's station was blank for RN total hours. During an interview on 3/19/2025…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-19 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 policy review, medical record review, observation and interview, the facility failed to ensure 2 of 3 nurses (Licensed Practical Nurse (LPN) B and LPN C) administered medications with a medication error rate of less than 5 % (percent). A total of 2 errors were observed out of 25 opportunities, resulting in a med error rate of 8%. The findings include: 1. Review of the policy titled, Administration of Eye Drops or Ointments, dated 2/2023 , revealed .Eye medications are administered as ordered by the physician and in accordance with professional standards of practice .If a second medication is required in the same eye, wait appropriate amount of time per manufacture's specifications (usually five minutes) . 2. Review of medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Legal Blindness, Glaucoma and Diabetes. Review of the Physican Orders dated 8/5/2022, revealed BRIMONIDINE 0.2 % (percent) EYE DROP Instill 1 drop in left eye three times a day .Glaucoma .…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-29 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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
Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 1 of 13 staff members (Certified Nursing Assistant (CNA) #1) failed to knock or request permission to enter residents' rooms during dining. The findings include: 1. Review of the facility's policy titled, Serving a Meal, dated 1/29/2024, revealed .It is the policy of this facility to serve meals that meet the nutritional needs of residents .if resident requests to eat in their room, knock on the door . 2. Observation in the resident's room on 1/22/2024 at 12:22 PM, revealed CNA #1 entered Resident #24's room and failed to knock or request permission during dining. 3. Observation in the resident's room on 1/22/2024 at 12:23 PM, revealed CNA #1 entered Resident #43's room and failed to knock or request permission during dining. 4. Observation in the resident's room on 1/22/2024 at 12:24 PM, revealed CNA #1 entered Resident #40's room and failed to knock or request permission during dining. 5. During an interview on 1/23/2024 at 3:40 PM, the Director 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.
Show the remaining 10 citations
- Potential for harm · D2024-01-29 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 provide 3 of 3 sampled residents (Resident #29, #44, and #202) with the Advanced Beneficiary Notice (ABN), Center for Medicare and Medicaid Services (CMS)-10055 when therapy services were discontinued, and 8 of 8 sampled residents (Resident #249, #250, #251, #252, #253, #254, #255, and #256) were not refunded their personal funds within 30 days of discharge. The findings include: 1. Review of the facility's policy titled, Advanced Beneficiary Notices (ABN), dated 2023, revealed .It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage .A Notice of Medicare Non-Coverage (NOMNC) .shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if resident is leaving the facility or remaining in the facility .the notice shall be provided at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending .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.
- Potential for harm · D2024-01-29 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, facility interviews with staff, and interview, the facility failed to report alleged violation involving injuries of unknown source to the State Agency, Police, Adult Protective Services (APS) and Long-Term Care Ombudsman immediately within the 2-hour time frame for 1 of 3 (Resident #199) sampled residents reviewed for abuse and resident rights. The failure of the facility to report an allegation of potential abuse related to an injury of unknown origin resulted in actual harm when Resident #199 sustained a fractured femur. The findings include: 1. Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed .Abuse Prevention Coordinator .responsible for reporting allegations or suspected abuse .to the state survey agency .and other officials .Possible indicators of abuse include .Physical injury of a resident, of unknown source .An immediate investigation is warranted .Reporting of all alleged violations to the .state agency, adult…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-29 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond 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 and interview, the facility failed to thoroughly investigate an alleged incident of abuse that included an injury of unknown source for 1 of 3 sampled residents (Resident #199) reviewed for abuse. The facility's failure to thoroughly investigate the alleged violation, prevent further potential abuse from occurring, and take appropriate corrective actions resulted in actual harm when Resident #199 sustained a fracture of unknown source. The findings include: 1. Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed . An immediate investigation is warranted .B. Written procedures for investigation include . Identifying staff responsible for the investigation . Investigating different types of alleged violations .Identifying and interviewing all involved persons, including the alleged victim .others who might have knowledge of the allegations .Focusing the investigation on determining if abuse, neglect,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-29 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and interview, the facility failed to implement Comprehensive Care Plans for 5 of 13 sample resident (Resident #27, #30, #38, #42, and #44) reviewed for care planning. Findings include: 1. Review of the medical record revealed Resident #27 was admitted on [DATE], with a readmission on [DATE], with diagnoses of Parkinson's Disease, Dementia, Chronic Kidney Disease, Anxiety Disorder, and Pain. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 1 which indicated he had severe cognitive impairment. Review of the Care plan dated 1/22/2024, revealed .resident has potential impairment of skin integrity r/t [related to] bowel and bladder incontinence .permethrin cream as ordered . Review of the Physician's Orders dated 1/16/2024, revealed .Permethrin [a topical anti-infective that treats scabies and other parasitic infections] .External Cream 5 % (Permethrin) .Apply to NECK DOWN topically at bedtime…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-29 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, and interview, the facility failed to include the resident and/or family member in the Interdisciplinary Team (IDT) Care Plan meeting for 1 of 9 sampled residents (Resident#19) reviewed for Care Plan Meetings. The findings include: 1. Review of the facility's undated policy titled, .Care Planning-Resident Participation revealed .This facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment implementation of care .The facility will notify the resident and/or resident representative, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care, as well as changes to the plan of care .The facility will honor the resident's right to participate in establishing the expected goals and outcome of the care, the type, amount, the frequency, and duration of care, and any other factors related to the effectiveness of the plan of care .The facility will discuss the plan of care with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided related to bathing for 1 of 3 sampled residents (Resident #44) reviewed for ADL care. The findings included: 1. Review of the facility's undated policy titled, Resident Bathing Policy, revealed .It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice .Residents will be provided showers as per request or as per facility schedule which is even rooms on M [Monday] .W [Wednesday] .F [Friday] .and odd rooms on Tu [Tuesday] .Th [Thursday] .Sat [Saturday] . 2. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE], with diagnoses of Dementia, Repeated Falls, and Diabetes. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #44 had a Brief Interview for Mental Status (BIMS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to accurately assess pressure ulcers for 1 of 3 sampled residents (Resident #19) reviewed for pressure ulcers. The findings include: 1. Review of the facility's undated policy titled, Pressure Injury Prevention and Management, revealed .Licensed nurses will conduct a pressure injury risk assessment .on all residents upon admission/re-admission, weekly x[for] four weeks, then quarterly or whenever the residents condition changes significantly .Findings will be documented in the medical record .The staging of pressure injuries will be clearly identified to ensure correct coding on the Minimum Data Set (MDS) .After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions . Review of the facility's undated policy titled, Pressure Injury Surveillance, revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review and interview, the facility failed to complete neurological (neuro) checks for 1 of 3 (Resident #44) sampled residents reviewed for accidents. The findings include: 1. Review of the facility's undated policy titled, .Head Injury, revealed .It is the policy of this facility to report potential head injuries to the physician and implement interventions to prevent further injury .Perform neuro checks as indicated .Continue monitoring for 72 hours following the incident . Review of the NURSING STAFF .TRAINING FOR EMPLOYEES dated 10/22/2023, revealed .FALL PROTOCOL .If they are NOT cognitively intact (13-15) neuro checks MUST be initiated unless the fall was witnessed . Review of the Neuro Check Assessment Form, revealed .Neuro Checks .q [every]15min [minute] x [times] 1hr [hour] .q 30 min x 1hr .q 1 hr x 4 hrs .q 4 hrs x 24 Hrs q shift until 72 hrs . 2. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE], with diagnoses of Dementia,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 care and services for an indwelling urinary catheter (a tube in the bladder that drains the urine) for 1 of 3 (Resident #30) sampled residents reviewed for indwelling catheters. The findings include: 1. Review of the facility's undated policy titled, Catheter Care, revealed .It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .Catheter care will be performed every shift .Gently separate the labia and expose the urinary meatus .Wipe from front to back with a clean cloth moistened with water and perineal cleanser (soap) .With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter .Dry area with towel .Bag and gather all supplies used . Review of the undated policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-29 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 6 Licensed Practical Nurse (LPN #4) nurses observed during medication administration left 1 of 3 (Medication Cart A) medication carts unlocked and unattended. The findings include: 1. Review of the facility's policy titled Medication Storage, dated 2023, revealed It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light ventilation, moisture control, segregation, and security .all drugs .will be stored in locked compartments ( .medication carts .all medication rooms) . 2.Observation at the Medication Cart A on 1/24/2024 at 8:33 AM, revealed the medication cart was left unlocked and unattended while LPN #4 was in Resident #23's room administering medications. During an interview on 1/24/2024 at 8:35 AM, LPN #4 was asked should the medication cart be left…
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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$23,963 in federal fines across 2 penalties.
- $9,110 — penalty dated 2025-06-26
- $14,853 — penalty dated 2024-01-29
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| COUNTY OF OBION | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/01/2011 |
| SHERWOOD, JAMES | Individual | W-2 MANAGING EMPLOYEE | — | since 04/01/2021 |
| BARKER, PATSY | Individual | CORPORATE DIRECTOR | — | since 07/01/2020 |
| BATEY, TRACEY | Individual | CORPORATE DIRECTOR | — | since 05/21/2007 |
| GANTT, TIMOTHY | Individual | CORPORATE DIRECTOR | — | since 01/09/2006 |
| LACEWELL, JANIS | Individual | CORPORATE DIRECTOR | — | since 05/21/2007 |
| MCGUIRE, BENNY | Individual | CORPORATE DIRECTOR | — | since 09/01/2008 |
| YARBOUGH, CHARLES | Individual | CORPORATE DIRECTOR | — | since 06/16/2008 |
1 organizational owner 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.
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Tennessee Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 445508. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-19, 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.