Cycle 1
Health 2025-01-15 · Fire 2025-01-15
15 health deficiencies
Top issue: Resident Rights (4 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Jackson, TN
Maplewood Health Care Center
1-star overall rating with 1-star inspections with abuse icon flag with $144,120 in total fines with 15 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
100 Cherrywood Place, Jackson, TN
(731) 668-1900
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
110
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ahava Healthcare
Operator or chain grouping
Approved since
1997-04-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.58
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.17
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.74
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.76
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,879
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.60% · Performance 22.16% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 9.53% · Performance 10.62% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.69
Baseline 76.92% · Performance 65.52% · Measure score 1.69 · Achievement 0 · Improvement 1.69
Adjusted total nurse staffing
2.26
Baseline 3.28 hours · Performance 3.72 hours · Measure score 2.26 · Achievement 2.26 · Improvement 1.27
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.37% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 88 · Observed rate 15.91% · Lower 95% interval 7.73% |
| Discharge to community | 41.11% |
50.57%
9.5 pts worse
|
Worse than the National Rate · Eligible stays 69 · Observed rate 30.43% · Lower 95% interval 30.43% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 101 · Denominator 101 |
| Falls with major injury | 0.99% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 101 |
| Discharge self-care score | 46.3% |
53.69%
7.4 pts worse
|
Numerator 25 · Denominator 54 |
| Discharge mobility score | 31.48% |
50.94%
19.5 pts worse
|
Numerator 17 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 2.97% |
2.29%
0.7 pts worse
|
Numerator 3 · Denominator 101 · Adjusted rate 1.93% |
| Healthcare-associated infections requiring hospitalization | 10.62% |
7.12%
3.5 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 20.29% · Lower 95% interval 6.75% |
| Staff COVID-19 vaccination coverage | 85.71% |
8.2%
77.5 pts better
|
Numerator 114 · Denominator 133 |
| Staff flu vaccination coverage | 22.46% |
42%
19.5 pts worse
|
Numerator 31 · Denominator 138 |
| Discharge function score | 42.59% |
56.45%
13.9 pts worse
|
Numerator 23 · Denominator 54 |
| Transfer of health information to provider | 97.87% |
95.95%
1.9 pts better
|
Numerator 46 · Denominator 47 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 1.59% |
25.2%
23.6 pts worse
|
Numerator 1 · Denominator 63 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.6
0.5 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 3.4 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
1.6
0.6 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.9 · Expected 2.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.5% |
89.9%
8.4 pts worse
|
93.4%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.0% · Q2 86.0% · Q3 73.4% · Q4 80.0% · 4Q avg 81.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.0% |
94.5%
1.5 pts worse
|
95.5%
2.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.6%
2.5 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.3% · Q3 1.1% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
11.8%
7.5 pts better
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.3% · Q3 4.8% · Q4 7.5% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 9.3% |
6.2%
3.1 pts worse
|
5.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 9.6% · Q3 9.6% · Q4 9.2% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.5% |
32.2%
17.7 pts better
|
19.6%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 15.4% · Q3 11.4% · Q4 14.3% · 4Q avg 14.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.3% |
18.1%
7.8 pts better
|
16.7%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 13.0% · Q3 11.7% · Q4 1.7% · 4Q avg 10.3% · 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 | 21.5% |
19.9%
1.6 pts worse
|
16.3%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 13.0% · Q3 23.0% · Q4 42.9% · 4Q avg 21.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.5% |
15.3%
4.2 pts worse
|
14.9%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 10.4% · Q3 27.2% · Q4 33.3% · 4Q avg 19.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.9%
0.2 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.5% · Q3 1.1% · Q4 2.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.2% |
20.2%
1 pts worse
|
19.8%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 20.8% · Q3 10.7% · Q4 29.6% · 4Q avg 21.2% |
| Percentage of long-stay residents with pressure ulcers | 8.8% |
5.4%
3.4 pts worse
|
5.1%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 10.1% · Q3 8.1% · Q4 8.7% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.5% |
79.6%
12.1 pts worse
|
81.7%
14.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 57.5% · Q2 67.6% · Q3 69.9% · Q4 78.3% · 4Q avg 67.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.0% |
11.2%
13.8 pts worse
|
12.0%
13 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 26.2% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.6%
About the same
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.4% |
79.8%
13.4 pts worse
|
79.7%
13.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.7% |
22.2%
9.5 pts worse
|
23.9%
7.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.7% · Observed 33.3% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-19 · Fire 2022-08-19
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-10-17 · Fire 2019-10-17
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-15
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-15
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-12
D · Potential for more than minimal harm
2022-08-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-08-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-08-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-08-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-08-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-03
D · Potential for more than minimal harm
2019-10-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-12-01
Inspection history
Recent health citations
J · Immediate jeopardy
2025-03-03
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 2025-03-13
G · Actual harm
2025-01-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-12
G · Actual harm
2025-01-15
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 2025-03-12
E · Potential for more than minimal harm
2025-01-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-15
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 2025-03-12
D · Potential for more than minimal harm
2025-01-15
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-15
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 2025-03-12
D · Potential for more than minimal harm
2025-01-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-15
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 2025-03-12
D · Potential for more than minimal harm
2025-01-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-15
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 2025-03-12
D · Potential for more than minimal harm
2025-01-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-12
G · Actual harm
2022-08-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-10-03
G · Actual harm
2022-08-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-03
F · Potential for more than minimal harm
2022-08-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-03
E · Potential for more than minimal harm
2022-08-19
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 2022-10-03
E · Potential for more than minimal harm
2022-08-19
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 2022-10-03
D · Potential for more than minimal harm
2022-08-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-08-19
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-08-19
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 2022-10-03
D · Potential for more than minimal harm
2022-08-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-08-19
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-10-03
E · Potential for more than minimal harm
2019-10-17
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 2019-11-01
E · Potential for more than minimal harm
2019-10-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-10-17
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 2019-11-01
D · Potential for more than minimal harm
2019-10-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-10-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-10-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-10-17
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 2019-11-01
Penalties and ownership
What sits behind the stars
$144,120
2025-01-15
Fine
Fine · fine $144,120
Fine
Ownership
Mfi Healthcare Tn LLC
5% Or Greater Direct Ownership Interest · Organization
Philipson Family Limited Liability Company, LLC
5% Or Greater Indirect Ownership Interest · Organization
Niederman, Anshel
5% Or Greater Indirect Ownership Interest · Individual
Labin, Shiya
5% Or Greater Indirect Ownership Interest · Individual
Neuman, Benjamin
5% Or Greater Indirect Ownership Interest · Individual
King, James
Operational/Managerial Control · Individual
Niederman, Anshel
Corporate Officer · Individual
Wall, Joseph
Operational/Managerial Control · Individual
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#2
West Tennessee Post Acute
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3-star overall rating with 3-star inspections with 7 recent health deficiencies
#3
Cypress Grove Post Acute
Jackson, TN
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
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