Cycle 1
Health 2022-05-12 · Fire 2022-05-12
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Mc Kenzie, TN
Ahc Mckenzie
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
175 Hospital Drive, Mc Kenzie, TN
(731) 352-3908
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
2002-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 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
0.48
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.76
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.11
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
2.68
CMS adjusted total nurse staffing hours
Case-mix index
1.92
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,348
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.81
Baseline 20.02% · Performance 19.66% · Measure score 3.81 · Achievement 3.81 · Improvement 0.68
Healthcare-associated infections
2.12
Baseline 8.62% · Performance 7.67% · Measure score 2.12 · Achievement 0.55 · Improvement 2.12
Total nurse turnover
2.34
Baseline 55.29% · Performance 54.10% · Measure score 2.34 · Achievement 2.34 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.42 hours · Performance 2.21 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.83% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 86 · Observed rate 11.63% · Lower 95% interval 7.8% |
| Discharge to community | 56.56% |
50.57%
6 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 50% · Lower 95% interval 42.18% |
| Medicare spending per beneficiary | 1.48 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 35 · Denominator 35 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 35 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 8.57% |
2.29%
6.3 pts worse
|
Numerator 3 · Denominator 35 · Adjusted rate 7.42% |
| Healthcare-associated infections requiring hospitalization | 7.67% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 10.42% · Lower 95% interval 4.22% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 98 |
| Staff flu vaccination coverage | 28.28% |
42%
13.7 pts worse
|
Numerator 41 · Denominator 145 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.04% |
25.2%
12.2 pts worse
|
Numerator 3 · Denominator 23 |
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 2.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.6
0.9 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.4 · Expected 1.6 · 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 | 2.6% |
3.6%
1 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.3% · Q3 3.5% · Q4 1.7% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 50.9% |
11.8%
39.1 pts worse
|
11.4%
39.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 34.5% · Q3 60.0% · Q4 90.6% · 4Q avg 50.9% |
| Percentage of long-stay residents who lose too much weight | 1.5% |
6.2%
4.7 pts better
|
5.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 75.4% |
32.2%
43.2 pts worse
|
19.6%
55.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.7% · Q2 71.7% · Q3 75.0% · Q4 82.4% · 4Q avg 75.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.4% |
18.1%
3.3 pts worse
|
16.7%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 23.1% · Q3 25.6% · Q4 18.4% · 4Q avg 21.4% · 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 | 14.6% |
19.9%
5.3 pts better
|
16.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 4.7% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.0% |
15.3%
8.3 pts better
|
14.9%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 12.8% · Q3 6.8% · Q4 6.4% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
0.9%
1.5 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.9% · Q3 1.3% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.9%
1.5 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.9% |
20.2%
2.3 pts better
|
19.8%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 15.9% · Q3 27.9% · Q4 23.0% · 4Q avg 17.9% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.4%
1.7 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 4.4% · Q3 4.3% · Q4 3.2% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
79.6%
19.2 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.3% |
11.2%
3.1 pts worse
|
12.0%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 14.0% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.0% |
1.6%
3.4 pts worse
|
1.6%
3.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.1% · Q3 7.0% · Q4 6.7% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.7% |
79.8%
16.9 pts better
|
79.7%
17 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.7% |
22.2%
5.5 pts worse
|
23.9%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.7% · Observed 30.2% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-21 · Fire 2019-08-21
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-10-24 · Fire 2018-10-24
0 health deficiencies
No concentrated health issue counts in this cycle.
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
2022-05-12
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 2022-06-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2022-05-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-06-10
D · Potential for more than minimal harm
2019-08-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-08-21
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Waters Of Mckenzie A Rehabilitation & Nursing Ctr
Mc Kenzie, TN
2-star overall rating with 3-star inspections with 8 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Huntingdon Health & Rehabilitation Center
Huntingdon, TN
2-star overall rating with 2-star inspections with abuse icon flag with $52,156 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Hillview Community Living Center
Dresden, TN
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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