Humphreys County Care And Rehabilitation
104 Fort Hill Road, Waverly, TN 37185 · Non profit - Other · 91 certified beds · (931) 296-2532 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- 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
- it has a citation for mishandling residents’ money or property (F0565)
- it has 1 actual-harm citation
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $14,013 in federal fines (most recent 2025-09-04)
- 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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 fell from 3 to 2 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 | 32.0% | 14.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 14.3% | 6.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.1% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.1% | 1.8% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 22.3% | 13.8% | 6.5% | worse 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 | 6.2% | 3.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 36.8% | 17.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 22.2% | 31.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.9% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.9% | 5.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 36.4% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.6% | 16.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.5% | 1.7% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 60.0% | 79.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 14.6% | 22.6% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 14.3% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.59 | 1.67 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 4.09 | 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.
54.0% 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 117 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 65.7% 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 70 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 35% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% 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 | 54.0%CMS range 45.3–60.2 | 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 | 10.9%CMS range 7.4–15.2 | 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 | 65.7% | 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 | 45.7% | 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 | 58.6% | 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 | 97.3% | 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 | 92.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.7% | 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 | 4.0% | 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 | 5.8%CMS range 3.3–10.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.13 | 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 91 beds and averages 69.6 residents a day — about 76% occupied, or roughly 21 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.28 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.82 is at or above 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 3.81 hrs/resident/day on weekends vs 4.47 on weekdays — 15% thinner on weekends. RN hours go from 0.66 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · G2025-09-04 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to provide care to ensure acceptable parameters of nutritional status were maintained for 2 of 2 (Resident #31 and #75) sampled residents reviewed for weight loss. This resulted in actual harm when the facility failed to implement interventions following a significant weight loss for Resident #31 and #75. The findings include: 1. Review of the facility policy titled, Weight Monitoring, dated 2/2023, revealed .The facility will ensure that all residents maintain acceptable parameters of nutritional status.Information gathered from the nutritional assessment.interventions will be identified, implemented, monitored and modified.consistent with the resident's assessed needs.A significant change in weight is defined as.5% [percent] change in weight in 1 month (30 days). Review of the facility policy titled, Nutritional Management, dated 1/20/2024, revealed .The facility provides care and services to each resident to ensure the resident…
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 · F2025-09-04 · tag F0922 — failed to maintain the building's systems — widespreadHave enough backup water supply for essential areas of the nursing home.
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 a sufficient emergency water supply was available. This had the potential to affect all 76 residents residing in the facility. The findings include: Review of the facility policy titled, Emergency Water Supply, dated 9/17/2024, revealed, .It is the policy of this facility to establish procedures to ensure that water remains available for drinking and essential functions when there is a loss of normal water supply.The volume of water needed.Drinking.1 gallon per day times the number of residents and staff.Handwashing.1 gallon per day time the number of staff.Cooking.1 gallon per day times the number of staff.Toilet flushing.2 gallons per day times the number of residents.Miscellaneous.1 gallon per day times the number of residents and staff.The Dietary Manager maintains a 3-day supply of bottled water for drinking and cooking. Observation and interview in the boiler room on 9/4/2025 at 5:30 PM, revealed 4 hot water heaters with a capacity of 116 gallons. Two of the 4 hot water heaters were not in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-04 · tag F0801 — patternEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on job description review, observation, and interview, the facility failed to maintain qualified dietary staff for 76 of 76 residents residing in the facility. The findings include: 1. Review of the undated job description titled, Director of Food Services, revealed .Education.Be a graduate of an accredited course in dietetic training approved by the American Dietetic Association.Experience.Must have, as a minimum five (5) years experience in a supervisory capacity in a hospital, nursing care facility, or other related medical facility. Must have training in cost control, food management, diet therapy .Specific Requirements.Must be registered as a Food Service Director in the state.Must be knowledgeable of food services practices and procedures as well as the laws, regulations, and guidelines governing food services functions in nursing care facilities. 2. During an interview on 9/2/2025 at 8:46 AM, Dietary Aide KK was asked who the Dietary Manager (DM) was. Dietary Aide KK stated .we don't have one.quit about 2 weeks ago. During an interview in the kitchen on 9/2/2025 at 2:45…
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 · D2025-09-04 · 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
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 dignity and respect during dining when 1 of 15 (Registered Nurse (RN)) PP staff members failed to use courtesy titles when addressing residents (Resident #69) and when 2 of 15 staff (Certified Nursing Assistant (CNA) Y and QQ) served meals in the hall to 3 of 3 (Resident #31, #51, and #75) residents observed for dining. Based on policy review, medical record review, observation, and interview the facility failed to maintain dignity and respect during dining when 1 of 15 (Registered Nurse (RN)) PP staff members failed to use courtesy titles when addressing residents (Resident #69) and when 2 of 15 staff (Certified Nursing Assistant (CNA) Y and QQ) served meals in the hall to 3 of 3 (Resident #31, #51, and #75) residents observed for dining. The findings include: 1. Review of the facility policy titled, Courtesy Titles dated 9/1/2017, revealed .It is the policy of this facility that all personnel are to treat…
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 · D2025-09-04 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 written information on how to formulate an Advance Directive for 9 of 24 (Residents #1, #6, #7, #22, #31, #49, # 54, #55, and #83) sampled residents. The findings include: 1.Review of the facility policy titled, Advance Directives, dated 9/1/2017, revealed .Prior to or upon admission of a resident to our facility, the Admissions Director or designee will provide written information.the right to formulate advance directives . 2.Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure and Hypertension. Review of the annual Minimal Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated that Resident #1 was cognitively intact. The facility was unable to provide documentation that the resident and/or Responsible Party (RP) were provided 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 · D2025-09-04 · 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, and interview, the facility failed to ensure residents were free from misappropriation of resident property when staff did not report an allegation of missing money for 1 of 4 (Resident #2) sampled residents reviewed for abuse, neglect, and misappropriation. The findings include: Review of the facility policy titled, Abuse, Neglect, and Misappropriation of Property, dated 9/15/2023, revealed .It is the organization's intention to prevent the occurrence of abuse.misappropriation of resident property, and to assure all alleged violations of federal or State laws which involve.misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Agency, and other appropriate State and local agencies in accordance with Federal and State law.The Facility Administrator is responsible for reporting all investigations results to applicable State agencies as required by Federal and State law.Misappropriation of resident…
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 · D2025-09-04 · 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, facility investigation review, medical record review, and interview, the facility failed to perform a thorough investigation for misappropriation of resident property for 1 of 4 (Resident #2) sampled residents reviewed for abuse, neglect, and misappropriation. The findings include: Review of the facility policy titled, Abuse, Neglect, and Misappropriation of Property, dated 9/15/2023, revealed .The organization's policy is that the Facility Administrator, or his or her designee, will conduct a reasonable investigation of each such alleged violation.Investigation Guidelines.The Facility Administrator will investigate all allegations, reports, grievances, and incidents that could potentially constitute.suspicion of crime.the Facility Administrator retains the ultimate responsibility to oversee and complete the investigation, and to draw conclusions regarding the incident.The investigation should include interviews of involved persons.alleged perpetrator, witnesses, and others who might have…
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 before2025-09-04 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 2 out of 18 (Residents #36 and #61) sample residents. The findings include: 1. Review of the facility policy titled, Comprehensive Care Plans, dated 2/5/2025, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident.The comprehensive care plan will describe, at a minimum, the following:.The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Resident specific interventions that reflect the resident's need. 2. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE], with diagnoses including Severe Dementia, Depression, and Anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score 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.
- Potential for harm · Dcited before2025-09-04 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to update or revise care plans for 2 of 18 (Resident #3 and #5) sampled residents. The findings include: 1.Review of the facility policy titled, Comprehensive Care Plans, dated 2/5/2025, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident.The comprehensive care plan will be reviewed and revised. 2. Review of the medical record revealed Resident #3 was admitted on [DATE], with diagnoses including Bipolar, Lower Back Pain, Wedge Compression Fracture of T7 (seventh thoracic vertebra] -T8 [eighth thoracic vertebra), and Wedge Compression Fracture of Lumbar Vertebra. Review of the admissions Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #3 was cognitively intact. Review of the facilities Incident Checklist dated 8/8/2025, revealed Resident #3 had a fall on 8/8/2025.…
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 · Dcited before2025-09-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure the environment was free from accident hazards when unsecure sharps and cleaning chemicals were in 5 of 76 (Residents #11, #18, #65, #66, and #83) sampled residents' rooms. The findings include: 1. Review of the facility policy titled, Sharps Disposal, dated 1/1/2024, revealed .The facility shall discard contaminated sharps into designated containers.Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers.Contaminated sharps will be discarded into container that are: Closable, Puncture resistant, Leakproof on sides and bottom, Labeled or color-coded in accordance with our established labeling system. Review of the facility policy titled, Resident Personal Belongings, dated 7/2025, revealed .If the facility staff identify items or substances that pose risks to residents' health and safety and are in plain view, they may confiscate them. 2. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, Daily Refrigerator Temperature Monitor log review, observation and interview, the facility failed to ensure medications were properly stored when medications were unsecure in 2 of 76 (Resident #22 and #55) resident rooms, and when 1 of 12 ( 100 Hall Med Cart ) medication storage areas were left unlocked and unattended, and when staff failed to complete temperature logs for 2 of 6 ( 200 hall and 700 hall ) medication refrigerators. The findings include: 1. Review of the facility policy titled, Medication Storage, dated 2/11/2024, 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 .All drugs and biologicals will be stored in locked compartments .During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart .Refrigerated Products .Charts are kept on each refrigerator and temperature levels…
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 14 citations
- Potential for harm · Dcited before2025-09-04 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 15 staff (Certified Nursing Assistant (CNA) NN) failed to perform hand hygiene during dining for 5 of 5 (Residents #15, #42, #43, #44, and #49) residents reviewed for dining, and when staff failed to properly store soiled linens for 1 of 76 (Resident #65) sampled residents. The findings include: 1. Review of the facility policy titled, Hand Hygiene, dated 6/11/2025, revealed, .All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.Hand hygiene is a general term used for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub. Review of the facility policy titled, Handling Soiled Linen, dated 6/5/2024, revealed .It is the policy of this facility to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-05 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, observation and interview the facility failed to ensure food was protected from contamination when 2 of 20 staff members (Certified Nursing Assistant (CNA) C and Admissions Coordinator ) touched the food with their bare hands, when 3 of 20 staff members (CNA C, and D, and the Admissions Coordinator) failed to perform hand hygiene, when 1 of 20 staff members (CNA B) placed a dirty meal tray back on a clean cart with clean trays, failed to ensure 2 of 2 ice machines were clean, and open and undated food in 1 of 1 pantry refrigerators. The findings include: 1. Review of the facility policy titled Hand Hygiene - [Named facility], revised 3/5/2024, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .Before applying and after removing personal protective equipment (PPE), including gloves . Review of the facility policy titled Meal Supervision…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-05 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the facility policy, observation, and interview the facility failed to provide a private space that prevented interference for the resident group meeting when 1 of 1 (Resident Council) sampled group was reviewed. The findings include: 1. Review of the facility's policy titled, Resident Council Meetings, dated 2/1/2024, revealed .This facility supports the rights of residents to organize and participate in resident groups, including a Resident Council . 2. Observation in the Activity Room on 6/4/2024 at 2:11 PM, revealed the Resident Council Meeting was being held in the Activity Room and the location was not being conducted in a private setting. The Activity Room had large openings area on each side of the room, with no doors and was accessible to anyone on the 100 Hall, Administrators Offices, and Dining Room. No signs were posted that the meeting was in progress. There were 17 resident members present. It was very noisy and hard to hear to the point that a microphone was provided to amplify the speaker. Observation in the Activity Room on 6/4/2024 at 2:37 PM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-05 · 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 facility policy review, medical record review, observation, and interview, the facility failed to implement Comprehensive Care Plans for 2 of 20 sample resident (Resident #33 and #46) reviewed for care planning. Findings include: 1. Review of the facility's policy titled Comprehensive Care Plan, dated 3/5/2024, revealed .It is the policy of this facility to develop and implement a comprehensive person - centered care plan for each resident, consistent with resident rights, that includes measures objectives and timeframe to meet a resident's medial nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will describe, at a minimum, the following .The services that are to be furnished to attain or maintain the resident's highest practicable physical, [NAME], and psychosocial well-being .Resident specific interventions that reflect the resident's needs . 2. Review of medical record revealed Resident #33 was admitted on [DATE],…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-05 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to update and revise the Care Plan for 1 of 20 sampled resident (Resident #29) reviewed for falls. The findings include: 1. Review of the facility's policy titled, Care Plan Revisions (Named Facility), dated 3/5/2024, revealed .The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change .The comprehensive care plan will be reviewed, and revised as necessary when a resident experiences a status change .The care plan will be updated with the new or modified interventions . 2. Review of medical record revealed Resident #29 was admitted on [DATE], with a diagnosis of Muscle Weakness, Ataxic Gait, and Psychotic Disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact with no behaviors identified.…
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 before2024-06-05 · 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 medical record review, observation, and interview, the facility failed to ensure for resident was free from accident hazards for 1 of 3 (Resident #65) reviewed for accident hazards. The findings include: 1. Review of medical record revealed Resident #65 was admitted on [DATE], with diagnoses of After Care Joint Replacement, Pain, Hypertension, Urinary Tract Infection, Dementia, and Anxiety Disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #65 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated she was cognitively impaired. Observation on 6/4/2024 at 9:09 AM, at the 700-Hall Nursing Station, revealed Resident #65 in her wheelchair going through the top left side drawer. The left side top drawer had the following items, 3 small tubes of toothpaste and a pair of blunt point scissors. The second drawer contained a can of Clorox 4 in one aerosol spray (Clean and disinfect multiple surfaces) and a can of suave aerosol hair spray. The Right side…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-05 · 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 facility policy review, medical record review, observations, and interview the facility failed to provide appropriate indwelling urinary catheter (a tube in the bladder that drains the urine) care for 2 of 2 sampled residents (Resident #45 and Resident #56) reviewed for catheter care. The Findings include: 1. Review of the facility's policy titled Catheter Care-(Named Facility), dated 3/5/2024 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 .drape resident to expose only the perineal area .using circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleanser (soap) .With a new moistened cloth, starting at the urinary meatus moving down, cleanse the shaft of the penis .With a new moistened cloth, starting at the urinary meatus moving outward, wipe the catheter . 2. Review of the medical record revealed Resident #45…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-05 · 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 facility policy review, medical record review and interview, the facility failed to provide ongoing communication of care with the dialysis center for 1 of 1 sampled resident (Resident #64) reviewed for dialysis. The findings include: 1. Review of the facility policy titled Hemodialysis, dated 6/3/2024 revealed .The facility will coordinate and collaborate with the dialysis facility to assure that .The resident's needs related to dialysis treatment are met .The provision of the dialysis treatments and care of the resident meets current standards if practice for the safe administration of the dialysis treatment .There is ongoing communication and collaboration for the development and implementation of dialysis care plan by nursing home and dialysis staff . 2. Review of medical record revealed Resident #64 was admitted on [DATE], with diagnoses of Atrial Fibrillation, Hypertension, End Stage Renal Disease, and Transient Ischemic Attack. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-05 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 policy review, medical records review and interview the facility failed to ensure residents were free from significant medication errors for 1 of 5 sampled residents (Resident #3) reviewed for unnecessary medications. The findings include: 1. Review of the facility policy tilted Medication Administration - (Named Facility), dated 3/5/2024, revealed .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .Obtain and record vital signs, when applicable or per physicians orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters . 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses of Dementia, Delusional Disorder, Depression, Anxiety and Hypertension. Review of the quarterly Minimum Data Set, dated [DATE],…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation and interview the facility failed to ensure medications were stored appropriately when unsecured and unattended medication for 2 of 67 sampled residents (Resident #3 and #65) were found at the bedside and at the nursing station. The findings include: 1. Review of the facility policy titled Resident Self-Administration of Medication - (Named Facility), revised 3/5/2024, revealed .It is the policy of this facility to support each resident's right to self administer medication. A resident may only self -administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely .When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider .The resident's cognitive status .Bedside medication storage is permitted only when it does not present a risk to confused residents .The manner of storage prevents access by other residents .The medications…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained for 5 of 7 sampled residents (#9, #39, #45, #56, and #319) reviewed for enhanced barrier precautions. The findings include: 1. Review of the facility's policy titled, Enhanced Barrier Precautions (Name Facility), dated 6/18/2024, revealed .It is the policy of this facility to implement enhanced barrier precaution for the prevention of transmission of multidrug-resistant organisms .An order for enhanced barrier precautions will be obtained for residents with any of the following .Wounds .indwelling medical devices .even if the resident is not known to be infected or colonized with a MDRO [multidrug-resistant organism] .Make gown and gloves available immediately near or outside of the residents room .Device care or use .central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline…
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 · Fcited before2022-07-28 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions, when opened and undated food items, soiled serving bowls, unclean storage carts and storage bins were in the Kitchen, and when bleach wipes were stored near food in the Kitchen. The facility had a census of 67 with 67 of those residents receiving a meal from the Kitchen. The findings include: Review of the facility's undated policy titled, Policy for Labeling and Dating Food, revealed Food must have a date when it is opened . Review of the facility's undated policy titled, Cleaning and Sanitation of Dining and Food Service Areas Policy, revealed .The food service staff will maintain the cleanliness and sanitation of the dining and food service areas . Observation in the Kitchen on 7/25/2022 beginning at 9:27 AM, revealed the following: a. 1 blue serving bowl on a tray on top of a metal cart with a clear brownish dried substance on the outside of the bowl b. a plastic container of bleach germicidal wipes sitting on top of a metal table…
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 · D2022-07-28 · 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 restraint assessments were completed for 1 of 1 sampled residents (Resident #9) reviewed for restraints. The findings include: Review of the facility's undated policy titled, Physical Restraint Policy, revealed .Provide an environment for residents which allows for no use of restraint(s) .It is the policy of this facility to use a physical restraint only after a Pre-Restraining Assessment . Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Atrial Fibrillation, Syncope, Ataxic Gait, and Dementia. Review of the Resident #9's PHYSICAL RESTRAINT INFORMED CONSENT, dated 10/16/2020 revealed .Self-releasing alarming seat belt physical restraint .Acknowledged Signatures .[Resident Representative] .Date 10/16/2020 . Review of the Facility Restraint - Physical (Quarterly/Annual Evaluation) form dated 5/10/2021, revealed Resident #9 was assessed for the use of 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.
- Potential for harm · Dcited before2022-07-28 · 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 ensure fall risk assessments were completed for 1 of 2 sampled residents (Resident #20) reviewed for falls. The findings include: Review of the facility's policy titled Fall Prevention and Management, revised 10/2021, revealed .The assessment will be completed upon admission, quarterly, annually, and/or if a change in condition . Review of the medical record, revealed the Resident #20 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dementia, Abnormalities of Gait and Mobility, Difficulty Walking, and History of Falling. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 was severely cognitively impaired, required extensive assistance for Activities of Daily Living (ADLs), and had 2 falls without injury. Review of the quarterly MDS assessment dated [DATE], revealed Resident #20 was severely cognitively impaired, required extensive assistance for ADLs, 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.
“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
$14,013 in federal fines across 2 penalties.
- $10,868 — penalty dated 2025-09-04
- $3,145 — penalty dated 2023-10-02
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 | Since |
|---|---|---|---|
| HUMPHREYS COUNTY CARE AND REHABILITATION | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/06/2019 |
| PULLEY, JANET | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2024 |
CMS files one row per role, so the 6 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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 445489. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-04, 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 →
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