12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Maryville, TN
1-star overall rating with 2-star inspections with abuse icon flag with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
936 Epworth Road, Maryville, TN
(865) 984-1660
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
181
Certified beds
Average residents
93
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Asbury Communities
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 4 overall / 4 health / 3 staffing / 5 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
RN hours / resident day
0.41
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
2.12
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.51
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.25
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
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.03
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
59%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
72%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
3,893
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
Readmission
4.97
Baseline 17.70% · Performance 19.13% · Measure score 4.97 · Achievement 4.97 · Improvement 0
Healthcare-associated infections
6.17
Baseline 5.90% · Performance 5.99% · Measure score 6.17 · Achievement 6.17 · Improvement 0
Total nurse turnover
0.95
Baseline 69.30% · Performance 62.86% · Measure score 0.95 · Achievement 0 · Improvement 0.95
Adjusted total nurse staffing
4.81
Baseline 4.25 hours · Performance 4.45 hours · Measure score 4.81 · Achievement 4.81 · Improvement 0.78
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.4% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 7.58% · Lower 95% interval 7.08% |
| Discharge to community | 49.78% |
50.57%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 47.46% · Lower 95% interval 39.65% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 44 · Denominator 44 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 44 |
| Discharge self-care score | 51.61% |
53.69%
2.1 pts worse
|
Numerator 16 · Denominator 31 |
| Discharge mobility score | 51.61% |
50.94%
0.7 pts better
|
Numerator 16 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 44 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.99% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 34 · Observed rate 0% · Lower 95% interval 3.13% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 94 |
| Staff flu vaccination coverage | 44.58% |
42%
2.6 pts better
|
Numerator 37 · Denominator 83 |
| Discharge function score | 58.06% |
56.45%
1.6 pts better
|
Numerator 18 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 67.86% |
25.2%
42.7 pts better
|
Numerator 19 · Denominator 28 |
Quality measures
| 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 1.2 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.6
0.4 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.9 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
89.9%
6.1 pts better
|
93.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 100.0% · Q3 89.2% · Q4 95.5% · 4Q avg 96.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
94.5%
4.2 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.0% |
3.6%
3.4 pts worse
|
3.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 11.0% · Q3 7.7% · Q4 4.5% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 28.8% |
11.8%
17 pts worse
|
11.4%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 38.1% · Q3 33.9% · Q4 22.6% · 4Q avg 28.8% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
6.2%
0.9 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 3.4% · Q3 5.5% · Q4 0.0% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.9% |
32.2%
7.3 pts better
|
19.6%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 28.3% · Q3 29.1% · Q4 21.4% · 4Q avg 24.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
18.1%
3.3 pts better
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 11.9% · Q3 15.2% · Q4 18.2% · 4Q avg 14.8% · 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 | 21.7% |
19.9%
1.8 pts worse
|
16.3%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.3% |
15.3%
9 pts better
|
14.9%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 17.2% · Q3 3.8% · Q4 0.0% · 4Q avg 6.3% · 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 | 1.5% |
1.9%
0.4 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.4% · Q3 1.5% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.7% |
20.2%
1.5 pts worse
|
19.8%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 22.3% · Q3 13.2% · Q4 32.6% · 4Q avg 21.7% |
| Percentage of long-stay residents with pressure ulcers | 1.0% |
5.4%
4.4 pts better
|
5.1%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.0% · Q3 1.8% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
79.6%
11.9 pts better
|
81.7%
9.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 98.9% · Q3 88.7% · Q4 85.0% · 4Q avg 91.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.9% |
11.2%
6.7 pts worse
|
12.0%
5.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 17.8% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.0% |
1.6%
2.4 pts worse
|
1.6%
2.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.1% · Q3 5.1% · Q4 5.2% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.9% |
79.8%
18.1 pts better
|
79.7%
18.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.5% |
22.2%
6.7 pts better
|
23.9%
8.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.5% · Observed 13.3% · Expected 20.5% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (8 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-18
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-18
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-11-07
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-07
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-07
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-11-07
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-11-07
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-07
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-11-07
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-07
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-12
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2019-10-12
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-10-12
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-10-12
Fire Safety
Install proper backup exit lighting.
Corrected 2018-10-04
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-10-04
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-10-04
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2018-10-04
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-03
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-03
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-17
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-10-17
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-17
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-17
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-17
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 2022-10-17
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-10-17
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-10-17
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2022-10-17
Health
Report COVID19 data to residents and families.
Corrected 2022-10-17
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-10-12
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-10-12
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 2018-10-22
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-10-22
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 2018-10-22
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2018-10-22
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2018-10-22
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2018-10-22
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2018-10-22
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2018-10-22
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2018-10-22
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2018-10-22
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-10-22
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2018-10-22
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-10-22
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2018-10-22
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-10-22
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 2018-10-22
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2018-10-22
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2018-10-22
Penalties and ownership
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3-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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