Waynesboro Post Acute & Rehabilitation
104 J V Mangubat Drive, Waynesboro, TN 38485 · Non profit - Corporation · 109 certified beds · (931) 722-3641 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 7 actual-harm citations
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,788 in federal fines (most recent 2025-10-22)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- its last standard health inspection was over 4 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 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 | 3 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 improved from 1 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 | 12.2% | 14.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 13.5% | 6.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 62.8% | 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 | 4.9% | 3.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 23.0% | 17.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 41.7% | 31.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 90.9% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.8% | 5.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 16.4% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 31.4% | 16.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.2% | 1.7% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 35.4% | 79.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 25.1% | 22.6% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 18.6% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.63 | 1.67 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.14 | 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.
44.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 48 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 38.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 39 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 0.20 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 44.2%CMS range 30.9–56.9 | 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 | 13.1%CMS range 9.3–17.8 | 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 | 38.5% | 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 | 38.5% | 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 | 28.2% | 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 | 98.0% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 0.0% | 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 | 2.0% | 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 | 7.3%CMS range 3.9–14.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.98 | 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 109 beds and averages 66.8 residents a day — about 61% occupied, or roughly 42 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.76 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 3.07 hrs/resident/day on weekends vs 3.72 on weekdays — 17% thinner on weekends. RN hours go from 0.55 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 26% is below 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 4 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
15 citations, most serious first — scroll within the box to see all.
- Actual harm · G2025-10-22 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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, Hospice contract review, medical record review, facility investigation review, Hospital record review, and interview, the facility failed to ensure residents were free from neglect for 1 of 3 (Resident #1) sampled residents reviewed for injury of unknown origin. On 11/10/2022, Resident #1 was found in bed by staff with multiple bruises to her right shoulder and right upper arm. On 11/18/2022, Resident #1 complained of pain in her right shoulder area. On 11/18/2022, the facility obtained an X-ray of the right arm/shoulder that revealed a displaced acute right transverse humerus shaft fracture (broken upper right arm usually caused by trauma/injury). During the investigation on 11/18/2022 it was found that on 11/8/2022, 2 Hospice staff members (Hospice Certified Nursing Assistant (CNA) F and CNA S) transferred Resident #1 without using a mechanical lift (a device used to help transfer a resident), heard her shoulder pop, and they did not report this to any staff at the facility. 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.
- Actual harm · G2018-06-27 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to timely notify the physician of a change in a resident's condition related to a pressure ulcer for 1 of 2 (Resident #50) sampled residents reviewed for pressure ulcers. The failure of the facility to timely notify the physician of a heel wound and obtain orders for treatment resulted in actual Harm for resident #50 when the wound deteriorated from a reddened area to a deep tissue injury/pressure ulcer. The findings included: The facility's Pressure Ulcer/Injury Risk Assessment policy dated 7/17, documented, .The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries .If a new skin alteration is noted .Notify attending MD [physician] .notify family, guardian . Medical record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses of Hemiplegia, Chronic Obstructive Pyelonephritis, Dysarthria…
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 · G2018-06-27 · 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 facility policy review, medical record review, observation, and interview the facility failed to revise the care plan to identify the development of a pressure ulcer for 1 of 2 (Resident #50) sampled residents reviewed with pressure ulcers. The failure of the facility to accurately perform skin assessments and revise Resident #50's care plan with updated interventions to address a reddened area when it was identified resulted in actual Harm to Resident #50. The findings included: The facility's Pressure Ulcer/Injury Risk Assessment policy dated 7/17, documented, .Steps in the Procedure .develop the resident centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the residents overall critical condition .Once inspection of skin is completed document the findings on a facility-approved skin assessment tool .If new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin .The care plan…
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 · G2018-06-27 · 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 National Pressure Ulcer Advisory Panel (NPUAP) reference guide, facility policy review, medical record review, observation, and interview, the facility failed to perform an accurate skin assessment to identify a pressure ulcer, failed to notify the physician of the development of a new pressure ulcer, failed to obtain new treatment orders, and failed to accurately assess a wound before it deteriorated to a Deep Tissue Injury (DTI) for 1 of 2 (Resident #50) sampled residents reviewed for pressure ulcers. The failure of the facility to accurately assess, implement interventions and document the findings before the pressure ulcer progressed into a Deep Tissue Injury (DTI) resulted in actual Harm for Resident #50. The facility failed to notify the physician, failed to obtain physician's orders for treatment of the pressure ulcer, and initiated treatment of the pressure ulcer without a physician's order. The findings included: Review of the NPUAP quick reference guide defined a Suspected Deep Tissue Injury…
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 · G2018-06-27 · 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 facility policy review, medical record review, observation, and interview, the facility failed to implement effective fall prevention interventions for 1 of 8 (Resident #60) sampled residents. The failure of the facility to implement effective fall interventions resulted in actual Harm when Resident #60 fell after the malfunction of a chair alarm, and sustained a hip fracture which required surgical repair. The findings included: The facility's undated PERSONAL SAFETY ALARMS policy documented, .Personal safety alarms are used to alert that a resident who is at risk for falls .attempting to stand .get out of bed .or leave a desired area .All personal alarms and alert devices must be maintained in good working order at all times .The intent of personal safety alarms is immediate response to the sounding of an alarm to minimize the potential for a fall or injury .SPECIFIC PROCEDURE .Check the alarm to ensure it is in working order. If it is not working properly, check/replace the batteries. If still not…
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 · G2018-06-27 · 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
Based on review of the Administrator's Job Description and the Director of Nursing's (DON) Job Description, and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of the residents, when they failed to recognize an ongoing concern with pressure ulcers and falls. The failure of the facility to be effectively and efficiently administered resulted in actual Harm to 1 of 2 (Residents #50) sampled residents with pressure ulcers. The failure of the facility to be effectively and efficiently administered resulted in actual Harm to 1 of 8 (Residents #60) sampled residents reviewed for falls. The administration failed to ensure skin assessments were ongoing and accurate, failed to ensure pressure ulcers were identified timely, failed to ensure the physician was notified timely of a pressure ulcer, and failed to ensure wound treatments were ordered by the physician prior to treatment initiation. Administration failed to ensure…
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 · G2018-06-27 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, medical record review, observation and interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to have an effective, ongoing quality program that identified, developed, implemented and monitored appropriate plans of action for pressure ulcers and falls. The QAA Committee failure to ensure an effective pressure ulcer prevention and treatment system resulted in actual Harm for Resident #50 when she developed a pressure ulcer to the right heel on 5/28/18, and the facility's Wound Nurse failed to assess the wound, failed to notify the physician, failed to revise the care plan related to the pressure ulcer, and initiated wound treatments without a physician's order. The QAA committee's failure to ensure an effective fall prevention system (an effective process to reduce patient falls) resulted in actual Harm for Resident #60. The chair alarm intervention implemented for Resident #60 was not functioning properly, and resulted in a fall with a hip fracture, which required surgical repair. The findings included: The facility's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-10-22 · tag F0842 — failed to keep accurate, complete medical records — widespreadSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the policy review, Electronic Medical Record (EMR) Provider Transition Checklist memo review, Administrator's email, medical record review, and interview, the facility failed to maintain access and availability to resident's medical records for 10 of 10 (Resident #1, #3, #5, #6, #7, #8, #9, #10, #11, and #12) sampled residents reviewed for medical records prior to 6/18/2024. The findings include: 1. Review of the RETENTION OF MEDICAL RECORDS, policy dated 10/1/2021, revealed .Medical records shall be retained by the facility in accordance with current applicable federal and state laws.Medical records of discharged residents will be retained for period required by State law.Six years from the date of discharge when there is no requirement in State law. Review of the undated facility policy titled, Resident Rights, revealed .The Facility shall protect and promote the rights of each Resident, including each of the following rights.The Resident or Legal Representative has the right, upon oral or written…
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 · D2025-10-22 · 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 facility policy review, medical record review, facility investigation review, Hospital record review, and interview, the facility failed to report an injury of unknown origin for 1 of 3 (Resident #1) sampled residents reviewed for abuse and neglect. The findings include: 1. Review of the facility policy titled, Abuse, dated 10/1/2021, revealed .This organization recognizes and respects that each resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation as defined in this subpart.Reporting.The organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source.are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily…
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 · D2025-10-22 · 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 review, Hospital record review, and interview, the facility failed to perform a thorough investigation for injury of unknown origin for 1 of 3 (Resident #1) sampled residents reviewed for abuse and neglect. The findings include: 1. Review of the facility policy titled, Abuse, dated 10/1/2021, revealed .Investigation Designated staff will immediately review and investigate all allegations .of abuse .The results of all investigation are to be communicated to the administrator or his or her designated representative and to other officials in accordance with the State law, including the State Survey Agency, within 5 working days of the incident .The organization will conduct analysis for trends and patterns related to .injuries of unknown origin . Review of the facility policy titled, Accidents and Incidents- Investigating and Reporting, dated 10/1/2021, revealed .All accidents or incidents involving residents, employees, visitors, vendors, etc.,…
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 · E2022-01-20 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, observation, and interview the facility failed to ensure medications were stored appropriately and securely when external medications and internal medications were stored together, and expired medications were in 4 of 7 medication storage areas (Treatment Cart, North Hall Medication Cart, [NAME] Hall Medication Cart, and [NAME] Hall Medication Room) reviewed and when 1 of 3 nurses (Licensed Practical Nurse (LPN) #1) gave the South Hall Medication Cart and Medication Room keys to the to an unauthorized staff member (the Housekeeping Supervisor) and left him unattended in the Medication Room. The findings include: Review of the facility's policy titled, Storage of Medications, revised 2007, revealed .The facility shall store all drugs in a safe, secure and orderly manner .The facility shall not use discontinued, outdated, or deteriorated drugs .All such drugs shall be returned to the dispensing pharmacy or destroyed .Drugs for external use .shall be stored separately from regular medications .Compartments .containing drugs and biologicals shall be locked when…
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 · D2022-01-20 · 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 promote care that maintained residents' dignity, respect, and quality of care when staff failed to provide dignity bags for 2 of 2 sampled residents (Resident #26 and #63) reviewed for urinary catheters. The findings include: Review of the facility's policy titled, Quality of Life - Dignity, revised on 8/2009, revealed .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality .Helping the resident to keep urinary catheter bags covered . Review of the medical record, revealed Resident #26 was admitted to the facility on [DATE] with diagnoses of Insomnia, Acute Kidney Failure, Chronic Respiratory Failure, Neurogenic Bladder, Metabolic Encephalopathy, Dementia, Parkinson's Disease, and Abdominal Aortic Aneurysm. Review of the Physician's Order dated 7/19/2021, revealed .SP [suprapubic] Cath [catheter] Care q [every] Shift Monitor and Document Output .…
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 · D2022-01-20 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1, dated October 2019, medical record review, and interview, the facility failed to ensure Death in Facility tracking assessments were completed for 2 of 23 sampled residents (Resident #2 and #8) reviewed for Minimum Data Set (MDS) assessments. The findings include: Review of the CMS Long-Term Care RAI 3.0 User's Manual version 1.17 pages 2-10 and 2-18, revealed .The facility must complete a Death in Facility tracking record MDS completion date .No later than .Discharge (Death)date + 7 calendar days . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] and discharged on 9/3/2021, due to a death in the facility. A Death in Facility assessment should have been completed on 9/10/2021. The facility was unable to provide a Death in Facility MDS assessment for Resident #2. Review of the medical record, revealed 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 · D2018-06-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to provide wound assessments for 1 of 1 (Resident #46) residents reviewed for arterial wounds. The findings included: Medical record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses of Osteoarthritis, Idiopathic Peripheral Neuropathy, Adjustment Disorder with Depressed Mood, Gastro-Esophageal Reflux Disease, Diabetes, Hyperlipidemia, Hypertension, Atherosclerotic Heart Disease, and Cerebral Infarction. Resident #46's care plan dated 1/30/18 documented, .At risk for skin breakdown r/t [related to] decreased mobility and inability to manage daily care needs .Approaches .skin inspections routinely .4/8/18 .Actual skin breakdown .(L) [left] ankle . The Departmental Notes dated 4/8/18 documented, .Resident noted with area to (L) outer ankle measuring 1.2cm [centimeters] x [by] 0.8cm . The first Wound Assessment Report for Resident #46's left ankle wound was dated 4/26/18. The Wound Care .Skin Integrity…
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 · D2018-06-27 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 honor the resident's request related to food choices for 1 of 3 (Resident #45) sampled residents reviewed for choices. The findings included: Medical record review revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Anxiety Disorder, History of Venous Thrombosis and Embolism, Presence of Left Artificial Hip Joint, Hypertension, Vascular Dementia, Adjustment Disorder with Depressed Mood, Gastro-Esophageal Reflux Disease, Dysphagia, Vitamin D Deficiency, Peripheral Neuropathy, Mixed Receptive-Expressive Language Disorder, and Osteoporosis. Observations in Resident #45's room on 6/26/18 at 5:20 PM, revealed a meal card on the dinner tray that documented, .Pureed .Dislikes .No turnip greens . There were turnip greens on the resident's tray. Interview with the Dietary Manager (DM) on 6/27/18 at 9:30 AM, in the Dietary office, the DM confirmed Resident #45 had a dislike of turnip…
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.
- 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
$8,788 in federal fines across 1 penalty.
- $8,788 — penalty dated 2025-10-22
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to LYON HEALTHCARE — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 1.7 | +0.3 vs chain |
| Health inspection | 2 of 5 | 1.8 | +0.2 vs chain |
| Staffing | 2 of 5 | 1.4 | +0.6 vs chain |
| Quality measures | 2 of 5 | 2.9 | -0.9 vs chain |
The other 10 homes this chain runs (chain average 1.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| TN 2 SNF OPERATIONS HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/17/2024 |
| BERGIN, MILES | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/17/2024 |
| IDELS, SHIMON | Individual | CORPORATE OFFICER | — | since 06/17/2024 |
CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
This home reported $299K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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 445518. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2022-01-20, 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.