Cycle 1
Health 2025-12-10 · Fire 2025-12-10
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Signal Mountain, TN
Ascension Living Alexian Village Tennessee
1-star overall rating with 1-star inspections with $214,408 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
671 Alexian Way, Signal Mountain, TN
(423) 886-0100
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
82
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ascension Living
Operator or chain grouping
Approved since
1978-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 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
0.69
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.32
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.20
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
2.01
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.95
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.44
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
0.72
CMS adjusted RN staffing hours
Adjusted total hours
4.40
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,428
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.77
Composite VBP score used to determine payment impact.
Payment multiplier
0.9843
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.17
Baseline 20.91% · Performance 20.43% · Measure score 2.17 · Achievement 2.17 · Improvement 0.74
Healthcare-associated infections
2.67
Baseline 7.20% · Performance 7.04% · Measure score 2.67 · Achievement 2.67 · Improvement 0.24
Total nurse turnover
0
Baseline 45.45% · Performance 68.97% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
5.87
Baseline 3.84 hours · Performance 4.75 hours · Measure score 5.87 · Achievement 5.87 · Improvement 4.18
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.21% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 3.74% · Lower 95% interval 6.34% |
| Discharge to community | 47.2% |
50.57%
3.4 pts worse
|
No Different than the National Rate · Eligible stays 93 · Observed rate 46.24% · Lower 95% interval 38.18% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.1% |
95.27%
1.8 pts better
|
Numerator 67 · Denominator 69 |
| Falls with major injury | 4.35% |
0.77%
3.6 pts worse
|
Numerator 3 · Denominator 69 |
| Discharge self-care score | 68.97% |
53.69%
15.3 pts better
|
Numerator 40 · Denominator 58 |
| Discharge mobility score | 63.79% |
50.94%
12.9 pts better
|
Numerator 37 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 1.45% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 69 · Adjusted rate 1.76% |
| Healthcare-associated infections requiring hospitalization | 7.04% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 64 · Observed rate 4.69% · Lower 95% interval 4.04% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 126 |
| Staff flu vaccination coverage | 64.15% |
42%
22.2 pts better
|
Numerator 102 · Denominator 159 |
| Discharge function score | 65.52% |
56.45%
9.1 pts better
|
Numerator 38 · Denominator 58 |
| 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 39 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 36.36% |
25.2%
11.2 pts better
|
Numerator 12 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.0 · Expected 1.3 · 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 1.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 77.2% |
89.9%
12.7 pts worse
|
93.4%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 81.1% · Q2 83.1% · Q3 77.8% · Q4 66.2% · 4Q avg 77.2% |
| 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 | 10.5% |
3.6%
6.9 pts worse
|
3.3%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 11.3% · Q3 9.7% · Q4 7.4% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.4% |
11.8%
7.4 pts better
|
11.4%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.5% · Q3 5.6% · Q4 4.7% · 4Q avg 4.4% |
| Percentage of long-stay residents who lose too much weight | 6.9% |
6.2%
0.7 pts worse
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 6.8% · Q3 8.9% · Q4 3.6% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.1% |
32.2%
6.1 pts better
|
19.6%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 25.8% · Q3 27.6% · Q4 32.8% · 4Q avg 26.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.7% |
18.1%
0.6 pts worse
|
16.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 15.7% · Q3 19.6% · Q4 21.6% · 4Q avg 18.7% · 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 | 30.5% |
19.9%
10.6 pts worse
|
16.3%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.3% · Q2 32.0% · 4Q avg 30.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.1% |
15.3%
8.8 pts worse
|
14.9%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 29.8% · Q3 24.5% · Q4 18.5% · 4Q avg 24.1% · 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 1.4% · Q2 1.5% · Q3 0.0% · Q4 3.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.8% |
20.2%
8.6 pts worse
|
19.8%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 21.9% · Q3 29.7% · Q4 31.4% · 4Q avg 28.8% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
5.4%
2 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 6.5% · Q3 8.7% · Q4 6.4% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 74.6% |
79.6%
5 pts worse
|
81.7%
7.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 68.3% · Q2 75.0% · Q3 81.6% · Q4 74.4% · 4Q avg 74.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.7% |
11.2%
3.5 pts worse
|
12.0%
2.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.7% · Observed 13.2% · Expected 10.0% · 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 | 81.0% |
79.8%
1.2 pts better
|
79.7%
1.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.9% |
22.2%
1.7 pts worse
|
23.9%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 18.4% · Expected 18.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-25 · Fire 2024-09-25
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-11-20 · Fire 2019-11-20
14 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
2025-12-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-12-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-12-29
F · Potential for more than minimal harm
2024-09-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-10
D · Potential for more than minimal harm
2019-11-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-12-20
Inspection history
Recent health citations
G · Actual harm
2025-12-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-11-17
D · Potential for more than minimal harm
2025-12-10
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-12-29
D · Potential for more than minimal harm
2025-12-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-12-29
D · Potential for more than minimal harm
2025-12-10
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 2025-12-29
D · Potential for more than minimal harm
2025-12-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-12-29
D · Potential for more than minimal harm
2025-12-10
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 2025-12-29
D · Potential for more than minimal harm
2025-12-10
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 2025-12-29
D · Potential for more than minimal harm
2025-12-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-29
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 2024-10-12
D · Potential for more than minimal harm
2024-09-25
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 2024-10-12
D · Potential for more than minimal harm
2024-09-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-12
D · Potential for more than minimal harm
2024-08-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-08-07
F756 · Pharmacy Service Deficiencies
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 2024-09-01
D · Potential for more than minimal harm
2024-08-07
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 2024-09-01
E · Potential for more than minimal harm
2023-12-13
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 2024-01-12
D · Potential for more than minimal harm
2023-12-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-13
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-01-12
J · Immediate jeopardy
2023-10-11
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 2023-11-21
J · Immediate jeopardy
2023-10-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-21
J · Immediate jeopardy
2023-10-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-21
J · Immediate jeopardy
2023-10-11
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 2023-11-21
J · Immediate jeopardy
2023-10-11
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-11-21
F · Potential for more than minimal harm
2023-10-11
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 2023-11-21
E · Potential for more than minimal harm
2023-10-11
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-11-21
D · Potential for more than minimal harm
2023-10-11
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 2023-11-21
D · Potential for more than minimal harm
2023-10-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-21
D · Potential for more than minimal harm
2023-10-11
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-11-21
D · Potential for more than minimal harm
2019-11-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-20
Penalties and ownership
What sits behind the stars
$214,408
2023-10-11
Fine
Fine · fine $214,408
Fine
$0
2023-10-11
Payment Denial
Payment Denial · denial start 2023-11-10 · 63 days
63 day denial
Ownership
Ascension Health Senior Care
Operational/Managerial Control · Organization
Binek, Robin
Corporate Director · Individual
Breedlove, Ryan
Corporate Director · Individual
Gronefeld, Kellie
Corporate Director · Individual
Miller, Aaron
W-2 Managing Employee · Individual
Musgrave, Lisa
Operational/Managerial Control · Individual
Shadbolt, Erin
Corporate Director · Individual
Smoot, Kenneth
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Life Care Center Of Red Bank
Chattanooga, TN
3-star overall rating with 2-star inspections with $8,512 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Siskin Subacute West
Chattanooga, TN
2-star overall rating with 1-star inspections with $93,919 in total fines with 3 fire-safety deficiencies in the latest cycle
#3
Life Care Center Of Hixson
Hixson, TN
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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