Cycle 1
Health 2025-06-18 · Fire 2025-06-18
3 health deficiencies
Top issue: Infection Control (1 deficiency)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Jackson, TN
Cypress Grove Post Acute
3-star overall rating with 3-star inspections with $17,355 in total fines with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
45 Forest Cove, Jackson, TN
(731) 424-4200
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
170
Certified beds
Average residents
88
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Links Healthcare Group
Operator or chain grouping
Approved since
2002-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
31 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.48
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.14
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.63
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.24
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.07
CMS adjusted total nurse staffing hours
Case-mix index
1.62
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,894
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.24
Composite VBP score used to determine payment impact.
Payment multiplier
0.9952
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
6.13
Baseline 9.35% · Performance 6.46% · Measure score 6.13 · Achievement 4.59 · Improvement 6.13
Total nurse turnover
6.55
Baseline 55.95% · Performance 36.92% · Measure score 6.55 · Achievement 6.55 · Improvement 5.62
Adjusted total nurse staffing
0
Baseline 3.32 hours · Performance 3.05 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.06% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 16.22% · Lower 95% interval 7.81% |
| Discharge to community | 38.49% |
50.57%
12.1 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 25% · Lower 95% interval 27.44% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 93.94% |
95.27%
1.3 pts worse
|
Numerator 31 · Denominator 33 |
| Falls with major injury | 3.03% |
0.77%
2.3 pts worse
|
Numerator 1 · Denominator 33 |
| Discharge self-care score | 63.64% |
53.69%
10 pts better
|
Numerator 14 · Denominator 22 |
| Discharge mobility score | 40.91% |
50.94%
10 pts worse
|
Numerator 9 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 3.03% |
2.29%
0.7 pts worse
|
Numerator 1 · Denominator 33 · Adjusted rate 2.33% |
| Healthcare-associated infections requiring hospitalization | 6.46% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 3.7% · Lower 95% interval 3.43% |
| Staff COVID-19 vaccination coverage | 84.62% |
8.2%
76.4 pts better
|
Numerator 99 · Denominator 117 |
| Staff flu vaccination coverage | 14.79% |
42%
27.2 pts worse
|
Numerator 21 · Denominator 142 |
| Discharge function score | 45.45% |
56.45%
11 pts worse
|
Numerator 10 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
89.9%
9.4 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.6%
1.1 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.9% · Q3 1.4% · Q4 1.3% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 99.6% |
11.8%
87.8 pts worse
|
11.4%
88.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.6% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
6.2%
3.5 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 4.8% · Q4 4.3% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 40.4% |
32.2%
8.2 pts worse
|
19.6%
20.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.3% · Q2 40.0% · Q3 38.5% · Q4 40.0% · 4Q avg 40.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.7% |
18.1%
5.6 pts worse
|
16.7%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 27.9% · Q3 25.5% · Q4 20.4% · 4Q avg 23.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.3% |
19.9%
14.6 pts better
|
16.3%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 10.7% · Q3 0.0% · Q4 0.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.4% |
15.3%
10.9 pts better
|
14.9%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.0% · Q3 6.5% · Q4 0.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
0.9%
1 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.0% · Q3 1.2% · Q4 1.8% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.9%
0.8 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.6% |
20.2%
2.6 pts better
|
19.8%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 12.1% · Q3 21.9% · Q4 15.2% · 4Q avg 17.6% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.4%
0.6 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.8% · Q3 5.2% · Q4 7.4% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.8% |
79.6%
8.2 pts better
|
81.7%
6.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 68.9% · Q2 89.9% · Q3 95.8% · Q4 94.2% · 4Q avg 87.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.9% |
11.2%
9.7 pts worse
|
12.0%
8.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 21.2% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.3% |
79.8%
7.5 pts better
|
79.7%
7.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.5% |
22.2%
10.7 pts better
|
23.9%
12.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 12.1% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-14 · Fire 2022-07-14
15 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-10-31 · Fire 2019-10-31
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-06-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-06-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-06-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-06-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-06-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-06-18
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-06-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-06-18
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-08-15
D · Potential for more than minimal harm
2022-07-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-07-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-08-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-18
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-18
G · Actual harm
2024-09-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-25
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-10-11
J · Immediate jeopardy
2022-07-14
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-06-08
J · Immediate jeopardy
2022-07-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-08
E · Potential for more than minimal harm
2022-07-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-07-14
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-07-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-07-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-07-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-07-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-07-14
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-07-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-07-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-07-14
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2022-08-04
D · Potential for more than minimal harm
2022-07-14
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-08-04
E · Potential for more than minimal harm
2019-10-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-11-14
D · Potential for more than minimal harm
2019-10-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-11-14
D · Potential for more than minimal harm
2019-10-31
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2019-11-14
D · Potential for more than minimal harm
2019-10-31
F642 · Resident Assessment and Care Planning Deficiencies
Health
Ensure a qualified health professional conducts resident assessments.
Corrected 2019-11-14
D · Potential for more than minimal harm
2019-10-31
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2019-11-14
D · Potential for more than minimal harm
2019-10-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-14
Penalties and ownership
What sits behind the stars
$17,355
2024-09-25
Fine
Fine · fine $17,355
Fine
Ownership
Links Healthcare Group LLC
5% Or Greater Direct Ownership Interest · Organization
Rodriguez, Curtis
5% Or Greater Indirect Ownership Interest · Individual
Tilford, Toby
5% Or Greater Indirect Ownership Interest · Individual
45 Forest Cove Tn LLC
5% Or Greater Mortgage Interest · Organization
Hammond, Jere
Operational/Managerial Control · Individual
Links Healthcare Group LLC
Operational/Managerial Control · Organization
Rodriguez, Curtis
Operational/Managerial Control · Individual
Sanders, Zabian
Operational/Managerial Control · Individual
Tilford, Toby
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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West Tennessee Post Acute
Jackson, TN
3-star overall rating with 3-star inspections with 7 recent health deficiencies
#2
Mission Convalescent Home
Jackson, TN
3-star overall rating with 4-star inspections with 3 recent health deficiencies
#3
Laurelwood Health Care Center
Jackson, TN
2-star overall rating with 2-star inspections with $126,516 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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