Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dickson Health And Rehab during CMS and state inspections, most recent first.
Failure to Implement RD Nutritional Recommendations for Residents With Weight Loss: The facility did not ensure that RD recommendations were reviewed, communicated, and implemented for three residents with weight loss and altered nutritional status. One resident with DM, dementia, malnutrition, nausea/vomiting, dysphagia, GERD, anxiety, and adult failure to thrive had RD recommendations for increased Med Pass, an appetite stimulant, and weekly weights that were not documented as followed up on. A second resident with Alzheimer’s, dementia, anorexia, and moderate protein-calorie malnutrition had an RD recommendation for Mighty Shake with lunch that was not documented as implemented. A third resident with dementia, poor intake, and meal refusals had RD recommendations for Med Pass TID and consideration of an appetite stimulant that were not documented as acted on, and interviews showed the DON, unit manager, and MD were not aware of the recommendations being processed.
Respiratory care orders were not followed or entered for several residents. Multiple residents on O2 had nasal cannulas or tubing left unchanged beyond the ordered weekly schedule, a resident with a trach had no trach care orders until later in the stay, and another resident’s oxygen orders were missing from the chart and MAR even though staff documented and observed O2 use at varying flow rates. Nursing leadership acknowledged the missing or uncompleted orders.
RN staffing was not maintained as required. Review of policy, time clock records, and interview showed the facility did not have an RN on duty for 8 consecutive hours on multiple days, and the DON was the only RN on duty on several dates. The DON confirmed she had covered shifts as the only RN and acknowledged that census affected whether she could be the only RN in the building.
The facility failed to ensure a qualified IP was employed to oversee the infection prevention and control program. The policy required an onsite IP with specialized IPC training, but the ADM stated the facility did not have an IP and that a Unit Manager without IP certification had been doing the duties. The ADM also stated the former DON had been the certified IP, but there had not been a certified IP at the facility since the DON left, and acknowledged the facility should have an onsite certified IP.
Unsecured Medication and Treatment Carts: An LPN left the North Hall med cart unlocked and unattended while sitting out of sight of it, and later another LPN used an unlocked, unattended treatment cart behind the nurse's desk to obtain wound care supplies for a resident with cerebral palsy, malnutrition, and a stage 4 pressure ulcer. Facility policy required drugs and biologicals to be stored in locked compartments, and the DON stated med carts should be locked at all times and treatment carts were locked as well.
An LPN failed to perform hand hygiene between glove changes during wound care for a resident with a stage 4 pressure ulcer, and another LPN did not wear an isolation gown while administering medication via PEG tube to a resident who was in EBP. The residents had significant medical needs, including dependence on staff care, a wound, and a feeding tube, and staff acknowledged the PPE and hand hygiene lapses.
The facility failed to maintain sanitary conditions in the kitchen, with observations of dirty floors, sticky surfaces, and unlogged refrigerator temperatures. Cleaning schedules were not consistently initialed, indicating non-compliance with cleaning protocols. A Registered Dietician confirmed the need for cleanliness and proper logging.
The facility failed to maintain proper infection control practices, as CNAs did not perform hand hygiene during meal pass, and dirty trays were placed with clean ones. PPE was not used during wound care for two residents, and a red biohazard bag with used PPE was found on the floor in a resident's room. Staff interviews revealed a lack of understanding of Enhanced Barrier Precautions.
The facility failed to implement an effective Infection Prevention and Control Program, as staff did not track organisms for UTIs or monitor for outbreaks and cross-contamination. Discrepancies were found in infection surveillance reports, and an LPN admitted to not tracking infections by organism or location. The administrator acknowledged the expectation for infection tracking, highlighting a gap between policy and practice.
The facility lacked a certified Infection Preventionist to oversee the Infection Prevention and Control Program, potentially affecting all 62 residents. An LPN, who had completed training but was not yet certified, was involved. The facility has been without a certified Infection Preventionist since early February, as confirmed by the Administrator.
A facility failed to honor a resident's food preferences, resulting in a deficiency. Despite a policy requiring adherence to individual food preferences, a cognitively intact resident with multiple health conditions reported receiving gravy on meals despite disliking it. An observation confirmed the presence of gravy on the resident's meal, contrary to tray instructions. The RD acknowledged that staff should follow the resident's choices.
A resident's admission assessment was not completed within the required timeframe due to the absence of an MDS coordinator. The assessment, which should have been completed within 13 days, was delayed to 19 days post-admission. The Regional RN confirmed the delay, acknowledging the failure to meet regulatory requirements.
A facility failed to complete a significant change assessment for a resident who enrolled in hospice care. The resident, with Alzheimer's Disease and Dementia, was readmitted to the facility with hospice care to follow. Despite receiving hospice care, the required assessment was not completed within the 14-day timeframe, as confirmed by a Regional RN.
The facility failed to complete resident assessments within the required time frames for two residents. One resident's annual MDS was completed late, while another's discharge MDS was not submitted on time. The Senior Director of Clinical Reimbursement confirmed the delays.
The facility failed to develop comprehensive care plans for two residents, neglecting to address key medical and psychological needs. One resident's care plan omitted Chronic Pain Syndrome and PTSD, while another's did not include dependencies in ADLs, a history of falls, and a Stage 4 pressure ulcer. The absence of an MDS Coordinator contributed to these deficiencies.
The facility failed to update care plans for four residents, neglecting to address specific medical needs such as PTSD, pressure ulcers, and hospice care. A resident with PTSD had no related interventions in their care plan. Another resident with multiple diagnoses lacked care plans for critical areas like pressure ulcers and diabetes. A third resident receiving hospice care had no care plan focus for hospice or antipsychotic use. Lastly, a resident with diabetes and fractures had no care plans for functional abilities and pain.
A resident with multiple medical conditions and dependent on staff for personal hygiene was found to have long, unkempt fingernails with dried debris, despite the facility's policy requiring daily cleaning and regular trimming. Observations and interviews confirmed the deficiency in nail care.
The facility failed to follow physician orders for PRN pain medication, administer medication through a PEG tube correctly, and collaborate with hospice services. A resident received oxycodone for pain levels below the prescribed threshold, another resident's medication was administered without checking stomach contents, and hospice documentation was outdated for a third resident.
A resident with severe cognitive impairment was found with open razors left unattended in their room, contrary to the facility's policy requiring sharp objects to be stored securely. Staff interviews confirmed the oversight, acknowledging the risk posed by the presence of razors, especially with residents who wander.
A facility failed to provide appropriate dialysis care for a resident, lacking a physician's order for hemodialysis, monitoring of the dialysis site, and accurate care planning. The resident, with multiple diagnoses including End Stage Renal Disease, was inaccurately documented as receiving peritoneal dialysis instead of hemodialysis. Staff interviews confirmed the absence of necessary orders and monitoring, and inaccuracies in the care plan were acknowledged.
A facility failed to obtain necessary physician orders for a resident's hospice care and foley catheter. The resident, with multiple diagnoses and cognitively intact, was admitted to hospice care per family request, but no physician's order was documented. Observations confirmed the presence of a foley catheter without a corresponding order. Interviews with an LPN and the DON verified the absence of required orders.
The facility failed to maintain RN coverage for 8 consecutive hours a day, 7 days a week, as required by their policy. Staffing records showed multiple instances of non-compliance in December 2024, January 2025, and February 2025. Interviews revealed challenges with staffing turnover and a negative work environment, contributing to the deficiency. The facility did not use agency staffing, relying on a contract DON.
The facility failed to document monthly pharmacist drug regimen reviews for two residents, one with multiple diagnoses including dementia and another with atrial fibrillation. Both residents were on complex medication regimens, but the facility lacked documentation of reviews or pharmacy recommendations for several months. The Regional Nurse Consultant confirmed the absence of these records, indicating a lapse in the process where the physician was supposed to implement and document the pharmacist's recommendations.
The facility failed to properly store and label medications, as an undated vial of Tuberculin was found in the medication refrigerator, and an RN left a medication cart unattended with unsecured medications. The DON confirmed these actions were against facility policy.
The facility consistently failed to maintain adequate staffing levels on weekends throughout 2024, resulting in a One Star Staffing Rating for all quarters. High turnover due to a negative work environment and ongoing vacancies for a CNA and two LPN positions contributed to the staffing deficiencies. The HR Manager was aware of the low staffing ratings but attributed them to callouts, while the DON was unaware of the issues.
Failure to Implement RD Nutritional Recommendations for Residents With Weight Loss
Penalty
Summary
The facility failed to provide care to maintain acceptable nutritional status and to review and implement dietary recommendations for three residents with documented weight loss. The facility policy stated that residents should maintain acceptable nutritional parameters, that the physician should be informed of significant weight change, and that the RD or Dietary Manager should be consulted for interventions. In the records reviewed, each of the three residents had diagnoses and assessments showing altered nutritional status, severe cognitive impairment, and weight loss, with RD notes recommending additional nutritional interventions and monitoring. For one resident with DM, dementia, malnutrition, nausea/vomiting, dysphagia, GERD, anxiety, and adult failure to thrive, the RD documented recommendations to increase Med Pass to 120 cc three times daily, consider an appetite stimulant, and obtain weekly weights. The record showed no documentation that these recommendations were followed up on. Interviews with the Interim DON, physician, unit manager, and medical director showed the physician was not made aware of the RD recommendations until later, and staff acknowledged the recommendations should have been addressed and communicated. For a second resident with Alzheimer’s, dementia, anorexia, moderate protein-calorie malnutrition, depression, dehydration, GERD, DM, and hypomagnesemia, the RD recommended sending Mighty Shake with lunch daily to support intake. The record contained no documentation that this recommendation was followed up on. The RD stated she sent recommendations weekly to facility leadership and did not know whether staff notified the physician or whether the recommendations were implemented. The Interim DON and physician stated they were unaware of the recommendation until later, and the medical director stated he did not receive it. For a third resident with dementia, anxiety, depression, diverticulitis, and edema, the RD documented that the resident had poor intake and many meal refusals and recommended restarting Med Pass 120 cc three times daily and considering an appetite stimulant. The record showed no documentation that these recommendations were implemented until later, when a supplement order was entered, and there was no documentation that Med Pass or an appetite stimulant had been started at the time of the review. Interviews showed the Interim DON, unit manager, and medical director were not aware of the recommendation being communicated or processed, and the unit manager stated she did not notify the provider of the RD’s recommendations.
Respiratory Care Orders Not Followed or Entered
Penalty
Summary
The facility failed to follow physician orders for respiratory care for multiple residents receiving oxygen therapy. Resident #8, Resident #13, Resident #15, Resident #17, and Resident #60 all had orders for oxygen tubing or nasal cannula changes on a weekly schedule, but observations and TAR reviews showed the tubing had not been changed as ordered. In several rooms, the nasal cannulas were observed dated 5/17/2026 or 5/11/2026 even though the ordered weekly change had not been completed on the expected Sunday dates. The Interim DON and Unit Manager acknowledged that oxygen tubing was expected to be changed according to the physician order. Resident #62 was admitted with diagnoses including malignant neoplasm of the pharynx, absence of larynx, diabetes, and dependence on supplemental oxygen, and had a tracheostomy. The record showed a care plan addressing the tracheostomy and humidified oxygen, but there were no physician orders for tracheostomy care in the chart until 5/27/2026. The Interim DON stated she was not aware there were no orders in the computer from admission until that date, and the Medical Director stated that tracheostomy care orders should have been placed on admission and took responsibility for not entering them. Resident #70 was admitted with COPD, heart failure, chronic respiratory failure, dependence on supplemental oxygen, panic disorder, and depression. Standing physician orders for shortness of breath and oxygen use were scanned into the record after admission but were never entered onto the MAR, and the chart contained no active orders for continuous oxygen administration. Progress notes repeatedly documented oxygen use at 2 L/min via nasal cannula, while observations showed the resident wearing oxygen connected to a tank or concentrator set at 3 L/min and later 2.5 L/min. During interview, nursing staff stated the oxygen order was not in the chart and that they would need to enter it from hospital paperwork, while the Interim DON stated an oxygen order should absolutely be present and that staff could not assume the correct oxygen rate without an order.
RN Staffing Not Maintained
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week for 11 of 31 days reviewed. Review of the facility policy titled, Nursing Services-Registered Nurse (RN), dated 10/2017, stated it was the facility’s intent to comply with RN staffing requirements by utilizing the services of an RN for at least 8 consecutive hours per day, 7 days a week, and that the Director of Nursing (DON) may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. Review of employee time clock sheets dated 4/25/2026 through 5/24/2026 showed no RN on duty for 8 consecutive hours on 11 dates, and the facility was unable to provide additional time sheets for those dates. The records also showed the DON was the only RN on duty on multiple dates, including one date in 11/2025 and six dates in the reviewed 4/25/2026 through 5/24/2026 period. During interview, the DON confirmed there should be an RN on duty for 8 consecutive hours, 7 days a week, and stated she had covered days as the only RN on duty, acknowledging that census affected whether she could be the only RN in the building for staffing.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to ensure employment of a qualified Infection Preventionist to monitor and maintain the Infection Prevention and Control Program. The facility policy titled, Infection Preventionist, dated 2/1/2026, stated the facility would employ one or more qualified individuals responsible for implementing the infection prevention and control program, including the antibiotic stewardship program, and that the IP would physically work on site and have specialized IPC training beyond initial professional training or education before assuming the role. During interviews, the Administrator stated the facility did not have an IP and that the Unit Manager had been performing IP duties without IP certification. The Administrator later stated the former DON had been the certified IP, that her last day of work was 3/24/2026, and that there had not been a certified IP at the facility since that date. The Administrator also stated the facility was wanting to get people certified and wanted the role to be filled by an RN, and acknowledged that the facility should have an onsite certified infection preventionist.
Unsecured Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure medications and treatment supplies were properly stored and secured when two nurses left the North Hall medication cart and the North Hall treatment cart unlocked and unattended. The facility policy stated that drugs and biologicals must be stored in locked compartments and that medications must be either under direct observation during administration or locked in the storage area/cart. During observation at the North Hall nurse's station, the medication cart was found unlocked and unattended while LPN B was sitting behind the nursing desk out of sight of the cart; when asked, LPN B acknowledged it was not locked and stated it should be. The Interim DON also stated that medication carts should be locked if unattended. Later the same day, the North Hall treatment cart was observed behind the nurse's desk, unattended and unlocked, while LPN A removed wound care supplies from it to perform treatment for Resident #32. Resident #32 had diagnoses including cerebral palsy, moderate protein-calorie malnutrition, and a stage 4 pressure ulcer of the right buttock. The resident's physician order directed daily and as-needed wound care using Dakin solution, collagen powder, calcium alginate with silver, and a dry dressing. LPN A stated the treatment cart was not locked and agreed it should have been. The DON later stated that medication carts should be locked at all times and that treatment carts were locked as well.
Infection Control Failures During Wound Care and PEG Medication Administration
Penalty
Summary
The facility failed to maintain infection prevention and control practices during wound care for a resident with a stage 4 pressure ulcer on the right buttock. The resident had diagnoses including cerebral palsy, moderate protein-calorie malnutrition, and a pressure ulcer of the right buttock, stage 4, and was dependent on staff for eating, toileting, bed mobility, and transfer, with always incontinent urinary and bowel status and hospice care noted. During observation of wound care, an LPN donned gown, mask, and gloves, cleansed the wound, removed gloves, and then put on clean gloves multiple times without performing hand hygiene between glove changes while applying Dakin’s solution, collagen powder, silver alginate, and a bordered dressing. The LPN later stated that hand hygiene should be performed between all glove changes and acknowledged that it was not done during the wound care. The facility also failed to ensure proper PPE use during enteral medication administration for a resident with a PEG tube. The resident had diagnoses including malignant neoplasm of the pharynx, acquired absence of larynx, diabetes, and dependence on supplemental oxygen, and the physician order review showed no order for Enhanced Barrier Precautions. During observation, an LPN performed hand hygiene, prepared and administered lorazepam via the g-tube, and wore gloves but did not wear an isolation gown while providing care. The LPN later stated that she should have worn an isolation gown, and the Interim DON stated that nurses would be expected to wear an isolation gown while administering medications to a resident in EBP.
Sanitation Deficiencies in Kitchen and Incomplete Cleaning Logs
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by multiple observations of unclean surfaces and equipment. The kitchen floor was found to be dirty with pieces of paper scattered, and a black rubber floor mat was sticky with crumbs and particles underneath. The deep fryer had a sticky buildup, and the oven handles were sticky with crumbs inside. Additionally, three dry food storage bins had crumbs and a thick sticky area on the outer edge of the lids. The facility also failed to log refrigerator temperatures on the nutrition refrigerator, and there was an undated item found inside. The facility's cleaning schedule showed multiple instances where staff failed to initial that cleaning duties were performed, indicating a lack of adherence to the cleaning schedule. Interviews with staff, including a Registered Dietician, confirmed that the kitchen should be clean and that cleaning logs should be initialed after assignments are completed. The nutrition refrigerator log for March 2025 had no temperatures recorded, and there was an undated pint of chocolate ice cream found. The Registered Dietician confirmed that items in the nutrition refrigerator should be dated and that the temperature log should be filled out daily.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by several observations and interviews. Certified Nursing Assistants (CNAs) D, L, and O did not perform hand hygiene during meal pass, and dirty trays were placed on the cart with clean trays. Additionally, Personal Protective Equipment (PPE) was not used or contained appropriately. During dining observations, CNA L applied gloves without performing hand hygiene and exited the room without removing the gloves. CNA O placed a dirty tray back on the clean cart and assisted a resident with a meal without performing hand hygiene. The Director of Nursing (DON) confirmed that hand hygiene should be performed before putting on gloves and that dirty trays should not be placed on the cart with clean trays. The facility also failed to don PPE when performing wound care for two residents. Resident #1, who was severely cognitively impaired and had a pressure injury, did not have Enhanced Barrier Precautions (EBP) in place during wound care. LPN K and CNA T did not don PPE during the treatment. Similarly, Resident #8, who was moderately cognitively impaired and had a history of recurrent urinary tract infections and diabetic ulcers, did not have PPE donned by LPN K during wound care. Random interviews with staff members revealed a lack of understanding of the proper reasons for using EBP. Furthermore, Resident #38, who was moderately cognitively impaired and tested positive for COVID-19, had a red biohazard bag with used PPE laying on the floor in their room. The DON confirmed that the biohazard bag should not be on the floor. These deficiencies highlight the facility's failure to adhere to infection prevention and control protocols, as outlined in their policies and CDC guidelines.
Failure to Implement Effective Infection Control Program
Penalty
Summary
The facility failed to establish and implement an effective Infection Prevention and Control Program, as evidenced by the inability to track organisms being treated and monitor for outbreaks and cross-contamination. The policy review and interviews revealed that the facility's program was not adequately identifying, reporting, investigating, and controlling infections and communicable diseases. Specifically, the facility did not track the organisms responsible for urinary tract infections (UTIs) in residents, which is crucial for monitoring potential outbreaks and cross-contamination. This deficiency was noted in the monthly infection surveillance reports for December 2024, January 2025, and February 2025, where the organisms being treated for UTIs were not listed, and discrepancies were found between the infection maps and surveillance reports. Interviews with LPN G highlighted a lack of knowledge and training in monitoring infections by organism and area within the facility. LPN G admitted to not tracking infections by organism or location and was unaware of the types of bacteria that would require isolation. Furthermore, LPN G confirmed that the information from the electronic medical record system was not correctly transferring to the infection surveillance reports, a problem that was only identified during the survey. The facility administrator acknowledged the expectation for infections to be tracked to monitor trends and cross-contamination, indicating a gap between policy and practice.
Lack of Certified Infection Preventionist in Facility
Penalty
Summary
The facility failed to provide a qualified Infection Control Preventionist responsible for monitoring and maintaining the Infection Prevention and Control Program, potentially affecting all 62 residents. According to the Centers for Medicare & Medicaid Services guidelines, facilities are required to have at least a part-time Infection Preventionist who must work onsite and cannot be an off-site consultant. The Infection Preventionist's role is crucial for mitigating infectious diseases, and specialized training is required. During interviews, an LPN admitted to not being certified yet, despite having completed the training. The facility has been without a certified Infection Preventionist since February 6, 2025, as confirmed by the Administrator.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, leading to a deficiency in promoting and facilitating resident self-determination. The facility's policy on resident food preferences, dated October 2024, mandates that nutritional assessments include evaluations of individual food preferences and that residents receive food prepared according to their needs and preferences. Despite this policy, a resident with diagnoses including Chronic Obstructive Pulmonary Disease, Morbid Obesity, Muscle Weakness, Bariatric Surgery Status, and Gastro-Esophageal Reflux Disease, who was cognitively intact with a BIMS score of 15, reported that they disliked gravy but continued to receive it on their meals. An observation of the resident's lunch tray confirmed the presence of gravy on the meat, contrary to the meal card instructions that specified 'No Gravy.' The Registered Dietician acknowledged that staff should adhere to the resident's choices.
Failure to Complete Timely Admission Assessment
Penalty
Summary
The facility failed to complete a comprehensive resident admission assessment within the required timeframe for one of the sampled residents. According to the Resident Assessment Instrument (RAI) Manual Version 3.0, the Minimum Data Set (MDS) and Care Area Assessment (CAA) for an admission assessment must be completed no later than 13 days after the resident's entry date. However, for Resident #215, who was admitted with multiple diagnoses including wedge compression fractures, acute respiratory failure, unspecified cirrhosis of the liver, and chronic systolic congestive heart failure, the admission MDS assessment was completed 19 days after admission, exceeding the required timeframe. The delay in completing the admission assessment was attributed to the facility being without an MDS coordinator since the end of January 2025. The Regional Registered Nurse, who was overseeing the assessments, confirmed during an interview that the admission MDS should be completed within 14 days of admission and acknowledged that the assessment for Resident #215 was not completed in a timely manner. This oversight resulted in a deficiency as the facility did not adhere to the regulatory requirements for timely resident assessments.
Failure to Complete Significant Change Assessment for Hospice Enrollment
Penalty
Summary
The facility failed to complete a significant change assessment for Resident #57, who was one of 21 residents reviewed. According to the CMS Resident Assessment Instrument (RAI) Version 3.0 Manual, a significant change assessment must be completed within 14 days when a resident enrolls in a hospice program. Resident #57, who had diagnoses including Alzheimer's Disease, Dementia, Hyperlipidemia, and Hypothyroidism, was readmitted to the facility with hospice care to follow. The Quarterly Minimum Data Set (MDS) indicated that the resident received hospice care during the assessment reference period. However, a significant change MDS was not completed within the required timeframe, as confirmed by a Regional Registered Nurse during a telephone interview.
Failure to Timely Complete Resident Assessments
Penalty
Summary
The facility failed to complete resident assessments using the Centers for Medicare & Medicaid Services-specific Resident Assessment Instrument (RAI) process within the regulatory time frames for two residents. According to the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, the Care Area Assessment (CAA) Completion Date for an admission assessment must be no later than 13 days after the entry date, and for an annual assessment, it must be no later than 14 days after the Assessment Reference Date (ARD). However, the facility did not adhere to these timelines for Resident #28 and Resident #48. Resident #28, who was admitted with diagnoses including diabetes, dementia, and depression, had an annual MDS with an ARD of 12/13/2024, but the completion date was 1/13/2025, exceeding the required completion date of 12/27/2024. Similarly, Resident #48, with conditions such as peripheral vascular disease and end-stage renal disease, had a discharge MDS with a completion date of 3/3/2025 that had not been submitted. The Senior Director of Clinical Reimbursement confirmed during interviews that the MDS submissions for both residents were not timely.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical and psychological needs. Resident #55, who was admitted with Chronic Obstructive Pulmonary Disease, Chronic Pain Syndrome, and PTSD, had a care plan that did not address the Chronic Pain Syndrome or PTSD. Despite having a BIMS score indicating moderately impaired cognition and requiring assistance with various activities of daily living, the care plan only focused on issues like Alcohol Dependence and Insomnia. The Director of Nursing confirmed that the care plan should have included the resident's pain and PTSD. Resident #215, admitted with multiple diagnoses including wedge compression fractures, acute respiratory failure, and chronic systolic congestive heart failure, had a care plan that only addressed transfer status and risk for altered nutritional/hydration status. The resident's Admission MDS assessment indicated no cognitive impairments but highlighted dependencies in toileting, dressing, and personal hygiene, as well as a history of falls and a Stage 4 pressure ulcer. The CAA Summary triggered care areas such as ADL function, urinary incontinence, falls, pressure ulcer, and pain, but these were not included in the care plan. The facility had been without an MDS Coordinator, which contributed to the oversight in care planning.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update or revise the care plans for four residents, leading to deficiencies in addressing their specific medical needs. Resident #55, who was admitted with diagnoses including PTSD, had a care plan that did not address the risk related to PTSD, despite having a moderately impaired cognition and requiring staff assistance with ADLs. The Director of Nursing confirmed that the PTSD diagnosis should have been included in the care plan. Resident #56, admitted with multiple diagnoses including Pneumonia and Diabetes, had a care plan that lacked focus on several critical areas such as vision, communication, ADLs, urinary incontinence, and pressure ulcers, despite these being triggered in the Care Area Assessment Summary. The resident also had an unstageable deep tissue injury that was not included in the care plan, and the Registered Dietician and Regional RN confirmed the absence of necessary care plan focuses. Resident #57, with Alzheimer's Disease and receiving hospice care, had a care plan that did not reflect a focus for hospice or the use of antipsychotics, despite receiving such medications. The Regional RN confirmed the absence of these focuses in the care plan. Similarly, Resident #220, with a history of fractures and diabetes, had a care plan that did not address functional abilities, urinary incontinence, pressure ulcers, and pain, even though these were marked for care planning in the CAA Summary.
Failure to Maintain Resident's Nail Hygiene
Penalty
Summary
The facility failed to ensure that a resident had clean and groomed fingernails, as required by their policy on nail care. The policy, dated October 2024, mandates daily cleaning and regular trimming of nails to prevent infections. However, observations and interviews revealed that the resident had long, unkempt fingernails with dried brown debris underneath, indicating a lack of proper nail care. The resident, who was admitted with multiple medical conditions including wedge compression fractures, acute respiratory failure, cirrhosis of the liver, and chronic systolic congestive heart failure, was dependent on staff for personal hygiene. Despite receiving showers and bed baths on specific dates, the resident's fingernails remained unclean, as confirmed by both the resident and the Director of Nursing during observations on March 3 and March 4, 2025.
Deficiencies in Medication Administration and Hospice Collaboration
Penalty
Summary
The facility failed to adhere to physician orders for the administration of PRN pain medication for a resident diagnosed with Atrial Fibrillation, Adult Failure to Thrive, and Radiculopathy. The resident, who was cognitively intact, received oxycodone for pain levels below the prescribed threshold of 7 on multiple occasions across several months, contrary to the physician's orders. The Director of Nursing confirmed that physician orders with specific parameters should be followed, indicating a lapse in compliance with medication administration protocols. Another deficiency involved the administration of medication through a PEG tube for a resident with Cerebral Palsy, Heart Failure, and Gastrostomy. The facility's policy required checking for residual stomach contents before administering medication, and if more than 100 ml was present, the medication should be withheld, and the physician notified. However, during an observation, an LPN failed to aspirate stomach contents before administering medication, which was confirmed as a necessary step by the Director of Nursing. Additionally, the facility did not maintain proper collaboration with hospice services for a resident with Parkinson's Disease, Dementia, and Anxiety. The care plan indicated the resident was receiving hospice services, but the last hospice documentation in the resident's record was from nearly a year prior. An LPN was unable to provide current hospice documents or evidence of collaboration with the hospice agency, as required by the facility's policy.
Failure to Secure Sharp Objects in Resident's Room
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for one resident, identified as Resident #34, who was found with open razors left unattended in their room. The facility's policy on needlesticks and cuts, dated April 2024, mandates that sharp objects should be placed in puncture-resistant containers to prevent injuries. Despite this policy, observations on multiple occasions revealed two blue disposable razors on Resident #34's nightstand. Interviews with staff, including CNAs and an LPN, confirmed that razors should not be left in resident rooms and should be stored in a secured area such as the shower room or central supply. Resident #34, who was admitted with diagnoses including severe cognitive impairment, muscle weakness, and restlessness, required supervision for personal hygiene. The resident's condition, combined with the presence of razors in their room, posed a potential risk. Staff acknowledged the oversight, noting that the facility had residents who wander, which further emphasized the need for secure storage of sharp objects. The facility administrator also confirmed that razors should not be in resident rooms and should be locked away to ensure safety.
Deficiencies in Dialysis Care for a Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident requiring such services. The deficiencies included the absence of a physician's order for the resident's hemodialysis treatments, lack of assessment and monitoring of the dialysis site for thrill and infection, failure to record weights and vital signs, and an inaccurate individualized care plan. The facility's policies on comprehensive care plans and dialysis care were not adhered to, as evidenced by the lack of documentation and communication with the dialysis clinic. The resident involved was admitted with diagnoses including Peripheral Vascular Disease, End Stage Renal Disease, Chronic Pain Syndrome, and Diabetes. The care plan inaccurately indicated that the resident received peritoneal dialysis, while the resident actually underwent hemodialysis. Interviews with facility staff confirmed the absence of necessary orders and monitoring, and the Senior Director of Clinical Reimbursement acknowledged the inaccuracies in the care plan.
Lack of Physician Orders for Hospice and Foley Catheter
Penalty
Summary
The facility failed to obtain a physician's order for hospice care and a foley catheter for Resident #53. The facility's policy requires a physician's order for hospice services and immediate care orders for residents. Resident #53 was admitted with diagnoses including Pleural Effusion, Type 2 Diabetes Mellitus, Atrial Fibrillation, and Diastolic Congestive Heart Failure. The resident was cognitively intact with a BIMS score of 13. Despite being admitted to hospice care per family request, there was no physician's order documented for hospice services or the foley catheter observed in the resident's room. Observations on 3/4/2025 confirmed the presence of a foley catheter without a corresponding physician's order. Interviews with an LPN and the DON confirmed the absence of required physician orders for both the foley catheter and hospice services.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, as required by their policy. The policy, dated March 2025, mandates that the community provides licensed nursing staff 24 hours a day, 7 days a week. However, a review of the facility's RN staffing records revealed multiple instances where this requirement was not met. Specifically, there was no RN coverage for 8 consecutive hours on several dates in December 2024, January 2025, and February 2025. This deficiency was confirmed through a review of the facility's staffing records and interviews with staff members. Interviews with the facility's staffing coordinator and Director of Nursing (DON) revealed challenges in maintaining adequate RN coverage due to staffing turnover and a negative work environment. The staffing coordinator acknowledged periods without a full-time DON, and the current DON, who started in February, was unaware of any concerns related to RN coverage. The facility had previously employed a travel contract DON from November 2024 through February 2025. The Administrator also acknowledged concerns with RN coverage and noted that the facility did not use agency staffing, relying instead on a contract DON.
Failure to Document Monthly Pharmacist Drug Regimen Reviews
Penalty
Summary
The facility failed to provide evidence of a monthly pharmacist drug regimen review for two residents, which is a requirement to ensure the safe administration of medications. Resident #38, who has multiple diagnoses including Type 2 Diabetes Mellitus, Heart Failure, Dementia, and Hypertension, was prescribed several medications such as Risperdal, Depakote, Hydrocodone-Acetaminophen, Duloxetine, and Trazodone. Despite the complexity of the medication regimen and the resident's moderate cognitive impairment, the facility did not have documentation of medication regimen reviews or pharmacy recommendations for December 2024, January 2025, and February 2025. Similarly, Resident #44, diagnosed with Atrial Fibrillation, Adult Failure to Thrive, and Radiculopathy, was prescribed medications including Buspirone, Eliquis, Duloxetine, Furosemide, and Oxycodone. The resident was cognitively intact, as indicated by a BIMS score of 13. However, the facility also failed to provide documentation of medication regimen reviews or pharmacy recommendations for the same months. During an interview, the Regional Nurse Consultant acknowledged the absence of these records, noting that the pharmacist's reports were supposed to be implemented by the physician and scanned into the resident's chart, which had not occurred.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as evidenced by two specific incidents. Firstly, an opened multi-dose vial of Tuberculin Purified Protein Derivative was found undated in the medication refrigerator in the East medication room. This was confirmed during an observation with an LPN and later acknowledged by the Director of Nursing (DON) during an interview. The facility's policy requires that medications with shortened expiration dates be labeled with the date they were opened, which was not adhered to in this instance. Secondly, during a medication administration, an RN left a medication cart unattended with several medications unsecured on top. The medications included Cozaar, Methocarbamol, Hydroxyzine HCL, Estradiol, Fluoxetine HCL, Acetaminophen, Omeprazole, and Docusate sodium. This action was contrary to the facility's policy, which mandates that medications should not be left unattended. The DON confirmed that medications should be secured and not left out, indicating a lapse in adherence to the facility's medication storage and administration protocols.
Inadequate Weekend Staffing and Low Staffing Ratings
Penalty
Summary
The facility failed to maintain adequate staffing levels on weekends for three out of four quarters in 2024, resulting in a One Star Staffing Rating for all four quarters. The facility's policy mandates 24/7 licensed nursing staff to ensure resident safety and well-being, but the Quarterly Payroll Based Journal (PBJ) reviews revealed excessively low weekend staffing and consistently low overall staffing ratings. Interviews with staff indicated a high turnover rate due to a negative work environment, contributing to the staffing shortages. The Staffing Coordinator acknowledged the turnover issues, while the Director of Nursing (DON) was unaware of the low weekend staffing concerns and the One Star Staffing Rating. The Administrator confirmed the staffing deficiencies and noted that the Human Resource Manager was responsible for entering PBJ data. The HR Manager was aware of the low staffing ratings but attributed them to callouts without providing a specific cause. The facility had ongoing vacancies for one Certified Nurse Assistant (CNA) and two Licensed Practical Nurse (LPN) positions, further exacerbating the staffing challenges.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dickson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare, Dickson | 0.1 mi | ★★★★★ | 4 | 0 |
| The Waters Of Cheatham, Llc | 21.1 mi | ★★★★★ | 14 | 0 |
| Life Care Center Of Centerville | 21.5 mi | ★★★★★ | 0 | 0 |
| Riverview Post Acute | 22 mi | ★★★★★ | 13 | 0 |
| Waverly Hills Post Acute | 22.5 mi | ★★★★★ | 1 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.