Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Patriot Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to provide necessary treatment and services for residents with pressure ulcers, resulting in harm for two residents. The facility did not perform wound care treatments and weekly wound assessments as per their policy, leading to the deterioration of pressure ulcers. Residents with various pressure injuries experienced lapses in wound care documentation and assessments, and interviews with facility staff confirmed that wound care was not provided as required.
The facility failed to serve palatable food at a safe and appetizing temperature for three residents who reported consistently receiving cold meals, particularly eggs. Observations confirmed that breakfast items were served at temperatures below standard, and staff interviews acknowledged frequent complaints about meal temperatures. The Dietary Manager noted a change in food brand as a factor, and the DON emphasized the importance of meal satisfaction.
A facility experienced significant resource shortages following a change in ownership, leading to deficiencies in resident care. Residents reported a lack of essential supplies like toilet paper, briefs, and food items, confirmed by staff who had to purchase supplies from retail stores. Budget cuts and vendor transitions further exacerbated the issue, affecting the quality and variety of food available to residents.
A resident with cognitive intactness and multiple health conditions was placed in a smaller shower chair, leading to him becoming stuck and feeling humiliated as staff laughed during the incident. The CNAs involved acknowledged their laughter was inappropriate, and the facility staff confirmed the larger chair was unavailable, resulting in the mishandling of the situation and compromising the resident's dignity.
A facility failed to create a care plan for a resident with Stage 3 pressure ulcers, despite policy requirements. The resident, with severe cognitive impairment and multiple diagnoses, developed pressure ulcers after admission. Interviews confirmed the necessity of a care plan, highlighting a deficiency in policy adherence.
The facility failed to ensure licensed nurses had the skills to detect changes in residents' conditions related to pressure ulcers, affecting nine residents. There was a lack of documentation for training in wound assessment and treatment, leading to missed assessments and undocumented wound care. This resulted in the deterioration of pressure injuries for several residents, with staff interviews confirming these deficiencies.
The facility failed to ensure proper infection control during wound care, as staff did not adhere to hand hygiene protocols and did not wear appropriate PPE for Enhanced Barrier Precautions. Multiple residents with pressure ulcers received care from LPNs and CNAs who did not follow these protocols, as confirmed by observations and interviews with the ADON and DON.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for residents with pressure ulcers. This deficiency was identified for nine residents, all of whom were reviewed for pressure ulcers. The facility did not perform wound care treatments and weekly wound assessments as per their policy, which contributed to the deterioration of pressure ulcers for two residents, resulting in harm. The facility's policy required licensed nurses to conduct full body assessments upon admission, weekly, and after any newly identified pressure injury, with findings documented in the medical record. However, these assessments and treatments were not consistently documented or performed. Resident #14, who was admitted with multiple diagnoses including Chronic Obstructive Pulmonary Disease and Diabetes, had a right buttock pressure ulcer that deteriorated due to missed wound care treatments and lack of weekly assessments. The wound increased in depth and developed eschar and undermining, with a foul odor noted during an observation. Similarly, Resident #18, admitted with conditions such as Parkinson's Disease and Malnutrition, had a sacral pressure ulcer that worsened in width and developed slough and eschar due to missed treatments and assessments. Other residents, including Resident #1, #2, #5, #11, #15, #16, and #19, also experienced lapses in wound care documentation and assessments. These residents had various pressure injuries that were not consistently assessed or treated according to physician orders. Interviews with facility staff, including the Director of Nursing and the Medical Director, confirmed that the lack of documentation indicated that wound care was not provided as required, and acknowledged staffing issues that may have contributed to these deficiencies.
Facility Fails to Serve Palatable and Safe Temperature Meals
Penalty
Summary
The facility failed to serve palatable food at a safe and appetizing temperature for three residents who were cognitively intact and able to express their dissatisfaction. Resident #7, #8, and #12 all reported that their meals, particularly the eggs, were consistently served cold. Observations confirmed that the breakfast tray line included scrambled eggs, sausage links, and gravy, which were served at temperatures significantly below the standard for safe and appetizing food. The Dietary Manager acknowledged the issue, noting that the change in food brand had led to complaints about the quality and temperature of the meals. Interviews with staff, including the Assistant Director of Nursing and a Licensed Practical Nurse, confirmed that complaints about cold meals were frequent, particularly regarding breakfast. The Director of Nursing also acknowledged receiving complaints about the temperature of the food, emphasizing the importance of meals to residents' satisfaction. The facility's policy on food safety requires that food be stored, prepared, and served in accordance with professional standards, which was not adhered to in this instance, leading to the deficiency.
Resource Shortages and Budget Cuts Impact Resident Care
Penalty
Summary
The facility failed to provide adequate resources to meet the needs of its residents, resulting in a deficiency in maintaining the highest practicable physical, mental, and psychosocial well-being of each resident. Multiple residents reported a lack of essential supplies, including toilet paper, briefs, wipes, and food items such as coffee and tea. These shortages were confirmed through interviews with residents and staff, who indicated that they had to purchase supplies from retail stores to meet the residents' needs. The deficiency was exacerbated by a recent change in facility ownership, which led to budget cuts and a transition in vendors. The new ownership reduced the food budget, resulting in limited food options and dissatisfaction among residents. Staff interviews revealed that the facility ran out of essential items like syrup for breakfast, and residents were served meals without the usual accompaniments. The dietary staff confirmed that the budget cuts affected the quality and variety of food available to residents. Staff members, including CNAs and LPNs, reported difficulties in obtaining necessary supplies for resident care, such as wound care materials and appropriately sized briefs. The facility's administration acknowledged the challenges posed by the transition, including issues with vendor contracts and delivery schedules. Despite efforts to address these issues, the facility continued to experience shortages, impacting the quality of care provided to residents.
Resident Dignity Compromised Due to Inappropriate Shower Chair Use
Penalty
Summary
The facility failed to maintain the dignity of a resident, who was cognitively intact and had a history of heart failure, depression, obesity, anxiety, and diabetes. The resident required extensive assistance with activities of daily living, including showering. During an incident, the resident was placed in a smaller shower chair, which was inappropriate for his size, leading to him becoming stuck. The resident reported feeling humiliated as he believed the staff were laughing at him during the incident. The incident involved three CNAs who assisted the resident in the shower room. The CNAs used baby oil to help free the resident from the chair, and during the process, one of the CNAs slipped, causing all three to laugh. The resident, unable to see the CNAs, perceived their laughter as directed at him, which made him feel bad and caused him emotional distress. The CNAs acknowledged that their laughter was inappropriate and understood why the resident felt the way he did. Interviews with facility staff, including the Administrator, Assistant Director of Nursing, and Director of Nursing, confirmed that the larger shower chair was not available at the time, leading to the use of the smaller chair. The staff recognized that the situation was mishandled and that the resident's dignity was compromised. The incident highlighted a failure to ensure the resident's right to be treated with dignity and respect, as outlined in the facility's policy on resident rights.
Failure to Develop Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with pressure ulcers. The facility's policy mandates the creation of a comprehensive care plan for each resident, which should include measurable objectives and timeframes to address the resident's medical, nursing, and psychosocial needs. However, the medical record review revealed that a resident admitted with diagnoses including Parkinson's Disease, Dementia, Anxiety, and Depression, developed two Stage 3 pressure ulcers that were not present upon admission. Despite this significant change, the facility did not create a care plan to manage the pressure ulcers. Interviews with the MDS Coordinator and the Director of Nursing confirmed that residents with pressure ulcers should have a care plan addressing these issues. The MDS assessment indicated that the resident was severely cognitively impaired, which further underscores the need for a detailed care plan. The lack of a care plan for pressure ulcer management represents a deficiency in the facility's adherence to its own policies and procedures.
Deficiency in Wound Care and Assessment
Penalty
Summary
The facility failed to ensure that licensed nurses had the necessary skills and knowledge to detect changes in residents' conditions related to pressure ulcers. This deficiency was identified for nine residents, where the facility's policy on pressure injury prevention and management was not adhered to. The policy required licensed nurses to conduct full body assessments upon admission, weekly, and after any newly identified pressure injury, with findings documented in the medical record. However, the facility was unable to provide documentation of certification or training for the Assistant Director of Nursing (ADON) responsible for wound care, and there was a lack of documentation for education or training related to wound assessment, staging, and treatment for the Licensed Practical Nurses (LPNs) involved. The medical records of several residents revealed significant lapses in wound care and documentation. For instance, Resident #1 had multiple pressure injuries that were not assessed or measured on a specified date. Resident #2's wound staging was incorrectly documented, and the wound care nurse inappropriately changed the staging of a wound. Resident #5's treatment administration records showed no documentation of wound care being provided on multiple occasions, leading to the deterioration of unstageable pressure ulcers. Similar issues were noted for other residents, where weekly wound assessments were not completed, and wound care was not documented as provided according to physician orders. The facility's failure to perform weekly wound assessments and provide wound care as ordered resulted in the deterioration of pressure injuries for several residents. For example, Resident #19 developed a deep tissue wound injury that progressed to an unstageable pressure injury due to the lack of assessments and care. Interviews with facility staff, including the Director of Nursing (DON), confirmed these deficiencies, with the DON acknowledging that the treatment nurse is responsible for completing accurate weekly wound assessments and the ADON is ultimately responsible for ensuring these assessments are completed.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections, as evidenced by multiple staff members not adhering to proper infection control protocols during wound care. Specifically, one Licensed Practical Nurse (LPN C) did not perform hand hygiene during wound care, which could lead to potential cross-contamination. Additionally, five staff members, including LPNs and Certified Nursing Assistants (CNAs), did not wear appropriate Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) while performing wound care. Resident #2, who was admitted with Parkinson's Disease, Dementia, Anxiety, and Depression, had two Stage 3 pressure ulcers that were not present on admission. During an observation, LPN C and CNA E entered the resident's room without PPE and performed wound care without following proper hand hygiene protocols. Similarly, Resident #11, with Alzheimer's Disease and a Stage 2 pressure injury, received wound care from LPN D and CNA G without the use of PPE. Resident #14, at risk for pressure ulcers, and Resident #18, with a Stage 4 pressure ulcer, also received wound care without staff wearing the necessary PPE. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that staff should wear gowns and gloves as PPE during wound care for residents under Enhanced Barrier Precautions. The DON also confirmed that hand hygiene should be performed before donning gloves, immediately after removing gloves, and during wound care. The failure to adhere to these protocols was observed and confirmed during the survey, indicating a deficiency in the facility's infection prevention and control program.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Henry County Health And Rehabilitation | 0.5 mi | ★★★★★ | 2 | 0 |
| Towne Square Care Of Puryear | 10.6 mi | ★★★★★ | 6 | 0 |
| Ahc Mckenzie | 14.9 mi | ★★★★★ | 6 | 0 |
| Waters Of Mckenzie A Rehabilitation & Nursing Ctr | 17.5 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Bruceton-hollow Rock | 17.7 mi | ★★★★★ | 3 | 0 |
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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 July 2026) and official state health department websites.