Cycle 1
Health 2024-07-09 · Fire 2024-07-09
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Johnson City, TN
Abundant Christian Living Community Rehabilitation
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2012 Sherwood Drive, Johnson City, TN
(423) 928-3168
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
103
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.56
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.86
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.89
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
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
2.52
CMS adjusted total nurse staffing hours
Case-mix index
1.79
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,709
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.17
Composite VBP score used to determine payment impact.
Payment multiplier
1.0019
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.69
Baseline 25.29% · Performance 18.53% · Measure score 7.69 · Achievement 6.27 · Improvement 7.69
Healthcare-associated infections
6.50
Baseline 10.49% · Performance 6.64% · Measure score 6.50 · Achievement 3.98 · Improvement 6.50
Total nurse turnover
4.29
Baseline 56.14% · Performance 46.15% · Measure score 4.29 · Achievement 4.29 · Improvement 2.69
Adjusted total nurse staffing
0.79
Baseline 2.42 hours · Performance 2.85 hours · Measure score 0.79 · Achievement 0 · Improvement 0.79
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.28% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 8.7% · Lower 95% interval 6.81% |
| Discharge to community | 58.51% |
50.57%
7.9 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 54.79% · Lower 95% interval 48.78% |
| Medicare spending per beneficiary | 1.4 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 62 · Denominator 62 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 62 |
| Discharge self-care score | 55.56% |
53.69%
1.9 pts better
|
Numerator 30 · Denominator 54 |
| Discharge mobility score | 48.15% |
50.94%
2.8 pts worse
|
Numerator 26 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 2 · Denominator 62 · Adjusted rate 3.55% |
| Healthcare-associated infections requiring hospitalization | 6.64% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 4.17% · Lower 95% interval 3.95% |
| Staff COVID-19 vaccination coverage | 10.89% |
8.2%
2.7 pts better
|
Numerator 11 · Denominator 101 |
| Staff flu vaccination coverage | 26.36% |
42%
15.6 pts worse
|
Numerator 29 · Denominator 110 |
| Discharge function score | 53.7% |
56.45%
2.8 pts worse
|
Numerator 29 · Denominator 54 |
| 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 | 100% |
96.28%
3.7 pts better
|
Numerator 29 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 23.26% |
25.2%
1.9 pts worse
|
Numerator 10 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.6
0.2 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.5 · 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 1.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.9%
10.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 2.1% |
3.6%
1.5 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.3% · Q3 1.5% · Q4 1.5% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.5% |
11.8%
1.3 pts better
|
11.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 8.1% · Q3 7.1% · Q4 6.9% · 4Q avg 10.5% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
6.2%
0.3 pts better
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.2% · Q3 3.2% · Q4 11.5% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 46.1% |
32.2%
13.9 pts worse
|
19.6%
26.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.7% · Q2 49.3% · Q3 42.9% · Q4 40.3% · 4Q avg 46.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.8% |
18.1%
11.7 pts worse
|
16.7%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 33.9% · Q3 25.5% · Q4 25.0% · 4Q avg 29.8% · 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 | 16.5% |
19.9%
3.4 pts better
|
16.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 11.0% · Q3 15.6% · Q4 18.5% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.2% |
15.3%
4.1 pts better
|
14.9%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 7.4% · Q3 10.0% · Q4 11.7% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.9%
0.5 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 1.5% · Q4 1.5% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.3% |
20.2%
2.9 pts better
|
19.8%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 15.8% · Q3 12.3% · Q4 15.5% · 4Q avg 17.3% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.4%
2.1 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 2.3% · Q3 1.4% · Q4 4.3% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
79.6%
20.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
11.2%
2.4 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 7.0% · Expected 8.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.6%
0.8 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.7% |
79.8%
17.9 pts better
|
79.7%
18 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 6.7% |
22.2%
15.5 pts better
|
23.9%
17.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 5.3% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-10-06 · Fire 2021-10-06
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-06-12 · Fire 2019-06-12
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-07-09
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-07-18
F · Potential for more than minimal harm
2019-06-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-07-09
E · Potential for more than minimal harm
2019-06-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-06-24
D · Potential for more than minimal harm
2019-06-12
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2019-06-25
D · Potential for more than minimal harm
2019-06-12
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-06-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-07-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-07-09
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 2024-07-18
D · Potential for more than minimal harm
2024-07-09
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-07-18
D · Potential for more than minimal harm
2021-10-06
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2021-10-29
D · Potential for more than minimal harm
2019-06-12
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-07-25
D · Potential for more than minimal harm
2019-06-12
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 2019-07-25
D · Potential for more than minimal harm
2019-06-12
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 2019-07-25
Penalties and ownership
What sits behind the stars
Ownership
Care Centers Management Consulting, Inc.
Operational/Managerial Control · Organization
Cawood-Gray, Lisa
Operational/Managerial Control · Individual
Cawood-Gray, Lisa
Corporate Officer · Individual
Colbaugh, Tyler
Operational/Managerial Control · Individual
Colbaugh, Tyler
W-2 Managing Employee · Individual
Lewis, Jimmy
5% Or Greater Direct Ownership Interest · Individual
Lewis, Jimmy
Operational/Managerial Control · Individual
Lewis, Jimmy
Corporate Director · Individual
Lewis, Jimmy
Corporate Officer · Individual
Moore, Christy
Operational/Managerial Control · Individual
Moore, Christy
W-2 Managing Employee · Individual
West, Anita
Operational/Managerial Control · Individual
West, Anita
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Agape Rehabilitation & Nursing Center, A Waters Cm
Johnson City, TN
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Princeton Transitional Care & Assisted Living
Johnson City, TN
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
The Waters Of Johnson City, LLC
Johnson City, TN
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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