Above average — CMS composite of the measures below.
The next survey window likely opens around May 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 West Tennessee Post Acute during CMS and state inspections, most recent first.
Failure to Maintain Resident Dignity and Privacy: An LPN administered a vaginal medication to a cognitively intact resident without closing the window blinds for privacy, and a severely cognitively impaired resident’s Foley catheter bag was observed hanging visibly from the bedframe without a privacy bag, despite orders requiring it to be in a privacy bag.
A facility failed to administer multiple ordered medications for two residents and failed to care plan an antipsychotic for one resident. One resident with diabetes, dementia, and depression had numerous daily meds not documented on the MAR, and another resident with spinal stenosis, CHF, HTN, bipolar disorder, diabetes, anxiety, and depression had several ordered meds not documented, including an antipsychotic; the care plan also did not address the antipsychotic. The DON stated residents should receive meds as ordered and that not documented meant it was not done, and the MDS Coordinator stated antipsychotics should be care planned.
Infection control practices were not followed for two residents on TBP and EBP. A CNA placed a soiled gown on the floor after assisting a resident on contact isolation, and an LPN failed to perform proper hand hygiene and did not wear a gown while providing care and administering medications via g-tube to a resident on EBP. The facility policy required gown and glove use for contact isolation and targeted gown and glove use for high-contact care under EBP.
A facility failed to ensure proper medication storage and security when an RN left medications unattended at a resident's bedside and returned unused medications to the cart by taping them. The medication cart was also left unlocked and unattended. The DON confirmed that these actions were against the facility's policy.
A facility failed to follow infection control practices during medication administration for a resident with a feeding tube. An RN did not perform hand hygiene and administered medication without wearing a gown, contrary to the facility's policy for enhanced barrier precautions. The DON confirmed that residents with indwelling devices should have enhanced precautions, including the use of gloves and gowns.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to promote and ensure residents were treated with dignity and respect for 2 of 54 sampled residents reviewed for resident rights. Facility policy required employees to treat all residents with kindness, respect, dignity, and privacy, but the observations showed those expectations were not followed for two residents. Resident #25 was cognitively intact with a BIMS score of 14 and had diagnoses including Myasthenia Gravis, gastrostomy, malnutrition, and depression. During medication administration, an LPN administered Miconazole vaginal cream to the resident’s labia but did not close the window blinds for privacy. The LPN acknowledged the blinds should have been closed, and the DON also stated the blinds should have been closed prior to medication administration. Resident #33 had diagnoses including CKD, diabetes, and dementia, and was severely cognitively impaired with a BIMS score of 5. Although the resident had an indwelling Foley catheter and orders indicated the catheter was to be in a privacy bag, observations showed the catheter bag hanging on the bedframe and visible from the door and hallway without a privacy bag covering it.
Failure to Administer Ordered Medications and Care Plan Antipsychotic Use
Penalty
Summary
The facility failed to follow physician orders and administer medications as prescribed for two sampled residents. Resident #18 was admitted with diagnoses including diabetes, dementia, and depression, and had physician orders for multiple daily medications, including aspirin, Caltrate, cholecalciferol, levocetirizine, meloxicam, metformin, oxybutynin, Colace, fluticasone, lidocaine-prilocaine, metoprolol tartrate, and pregabalin. Review of the MAR for April 26, 2026, showed these medications were not documented as administered. The resident’s admission MDS showed a BIMS score of 13, indicating cognitive intactness, and the resident received antianxiety, antiplatelet, hypoglycemic, and anticonvulsant medications. Resident #53 was admitted with diagnoses including spinal stenosis, CHF, HTN, overactive bladder, bipolar disorder, diabetes, COPD, anxiety, and depression. Physician orders included buspirone, oxybutynin, gabapentin, Vraylar, fluoxetine, and carvedilol, but the MAR for April 26, 2026, did not document administration of fluoxetine, oxybutynin, Vraylar, carvedilol, buspirone, or gabapentin. The care plan dated 4/10/2026 also failed to care plan an antipsychotic medication. During interview, the MDS Coordinator stated antipsychotics should be care planned, and the DON stated residents should receive medications as ordered and that not documented meant it was not done; the DON also stated an antipsychotic medication should be care planned.
Infection Control Practices Not Followed for Residents on Isolation and EBP
Penalty
Summary
The facility failed to ensure infection control practices were followed to prevent the spread of communicable diseases when staff did not properly store and use PPE for residents on transmission-based precautions and enhanced barrier precautions. The facility policy stated that transmission-based precautions are used for residents with signs and symptoms of transmissible infection, that staff and visitors wear a disposable or washable gown upon entering a contact isolation room and remove it before leaving, and that enhanced barrier precautions require targeted gown and glove use during high-contact resident care activities, including for residents with chronic wounds and/or indwelling medical devices. Resident #8 was admitted with diagnoses including UTI, bacteremia, anxiety, and depression, and had a BIMS score of 12 indicating moderate cognitive impairment. A physician order directed contact isolation for ESBL-positive urine. During observation, a CNA donned a gown and gloves before entering the resident’s room and assisted with tray set-up, but removed the soiled gown and gloves and placed the gown on the floor before exiting the room. When interviewed, the CNA stated the gown should have been placed in the biohazard bag and acknowledged it should not have been placed on the floor. The DON stated soiled gowns should be placed in a red bag for laundry and not on the floor. Resident #25 was admitted with diagnoses including myasthenia gravis, gastrostomy tube, malnutrition, and depression, and had a BIMS score of 14 indicating cognitive intactness. Physician orders included enhanced barrier precautions during high-contact time and medications administered via gastrostomy tube as needed. During medication administration, an LPN applied miconazole vaginal ointment, removed and replaced a glove without hand hygiene, recapped the tube, performed hand hygiene at the sink, and turned off the faucet with a bare hand. The LPN then administered crushed medications via gastrostomy tube without donning a gown despite the resident being on enhanced barrier precautions. The LPN stated PPE was not needed unless there was a sign on the door, then acknowledged the resident did have a sign and that a gown should have been worn for gastrostomy tube medication administration. The DON stated staff should wear gown and gloves for enhanced barrier precautions and should perform hand hygiene before entering rooms and before and after glove removal, using a paper towel to turn off the faucet.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure proper storage and security of medications, as evidenced by several observations and interviews. During a medication administration, a registered nurse (RN A) was seen leaving medications unattended at a resident's bedside and returning unused medications to the medication cart by taping them, which is against the facility's policy. The RN left the medication cart unlocked and unattended outside the resident's room, which was out of sight, while administering medications to a resident. The Director of Nursing (DON) confirmed during an interview that medication carts should not be left unlocked or unattended, and that nursing staff should not leave medications at a resident's bedside unattended. The DON also stated that unused medications should be discarded and not taped, confirming the facility's policy. These actions and inactions by the staff member led to a deficiency in the facility's medication storage and security practices.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain infection prevention practices during medication administration for a resident with a feeding tube. The Registered Nurse (RN A) did not perform hand hygiene before entering the resident's room and administered medication via the resident's peg tube without wearing a gown, which is required under the facility's policy for enhanced barrier precautions. The facility's policy mandates that gloves and gowns should be worn during high-contact activities such as device care or use, including feeding tubes. Resident #211, who was admitted with conditions including Ataxia, Chronic Obstructive Pulmonary Disease, Anxiety, Quadriplegia, and Gastrostomy, was receiving tube feedings. The care plan indicated the need for monitoring the feeding tube site for signs of infection. During an interview, the Director of Nursing confirmed that residents with indwelling devices should be under enhanced barrier precautions, and appropriate PPE should be used during medication administration. However, these precautions were not followed, as observed during the medication administration process.
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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 Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cypress Grove Post Acute | 0.1 mi | ★★★★★ | 0 | 0 |
| Mission Convalescent Home | 1.7 mi | ★★★★★ | 0 | 0 |
| Laurelwood Health Care Center | 2.8 mi | ★★★★★ | 5 | 1 |
| Maplewood Health Care Center | 3.1 mi | ★★★★★ | 3 | 0 |
| Northbrooke Post Acute | 3.7 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.