Cycle 1
Health 2025-05-28 · Fire 2025-05-28
4 health deficiencies
Top issue: Environmental (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lexington, TN
Briarwood Community Living Center
1-star overall rating with 3-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
41 Hospital Drive, Lexington, TN
(731) 968-6629
Overall
1 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
55
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Community Eldercare Services
Operator or chain grouping
Approved since
1994-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 2 overall / 2 health / 3 staffing / 2 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
0.44
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.63
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.27
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.87
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
3.47
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
100%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,334
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Performance 63.16% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.57
Baseline 3.29 hours · Performance 3.81 hours · Measure score 2.57 · Achievement 2.57 · Improvement 1.57
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| 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 | Not Available |
2.29%
|
Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.23% |
8.2%
5 pts worse
|
Numerator 2 · Denominator 62 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| 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 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
89.9%
9.3 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 96.9% · 4Q avg 99.2% |
| 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 | 14.0% |
3.6%
10.4 pts worse
|
3.3%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 13.8% · Q3 12.9% · Q4 15.6% · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
11.8%
11.8 pts better
|
11.4%
11.4 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 who lose too much weight | 9.9% |
6.2%
3.7 pts worse
|
5.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 8.3% · Q3 12.0% · Q4 9.5% · 4Q avg 9.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.8% |
32.2%
7.6 pts worse
|
19.6%
20.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 37.5% · Q3 38.5% · Q4 43.5% · 4Q avg 39.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.9% |
18.1%
18.8 pts worse
|
16.7%
20.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 33.3% · Q3 31.8% · Q4 50.0% · 4Q avg 36.9% · 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 | 41.3% |
19.9%
21.4 pts worse
|
16.3%
25 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 41.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.8% |
15.3%
12.5 pts worse
|
14.9%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 27.3% · Q3 25.0% · Q4 23.8% · 4Q avg 27.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.9%
1.9 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 21.8% |
20.2%
1.6 pts worse
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 18.6% · Q3 20.7% · Q4 20.0% · 4Q avg 21.8% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
5.4%
2.5 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 6.1% · Q3 5.5% · Q4 9.0% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
79.6%
16.6 pts better
|
81.7%
14.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.5% · Q2 96.7% · Q3 100.0% · Q4 100.0% · 4Q avg 96.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
11.2%
1.7 pts worse
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 15.0% · Expected 13.0% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.9% |
79.8%
3.9 pts worse
|
79.7%
3.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 10.0% |
22.2%
12.2 pts better
|
23.9%
13.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 10.0% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-03 · Fire 2024-07-03
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-06-07 · Fire 2023-06-07
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-05-28
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 2025-07-07
D · Potential for more than minimal harm
2025-05-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-05-28
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-05-28
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-05-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-07
D · Potential for more than minimal harm
2024-07-03
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 2024-07-18
D · Potential for more than minimal harm
2024-07-03
K321 · Smoke Deficiencies
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 2024-07-10
D · Potential for more than minimal harm
2024-07-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-07-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-07-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-07-03
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 2024-07-17
D · Potential for more than minimal harm
2024-07-03
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-07-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-08
D · Potential for more than minimal harm
2023-06-07
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-06-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-06-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-12
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-28
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 2025-07-15
D · Potential for more than minimal harm
2025-05-28
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 2025-07-15
D · Potential for more than minimal harm
2025-05-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-05-28
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-07-15
E · Potential for more than minimal harm
2024-07-03
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 2024-07-19
E · Potential for more than minimal harm
2024-07-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-07-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-07-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-07-03
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-03-06
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-03-18
D · Potential for more than minimal harm
2024-03-06
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 2024-03-18
D · Potential for more than minimal harm
2024-03-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-18
E · Potential for more than minimal harm
2023-06-07
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 2023-06-23
D · Potential for more than minimal harm
2023-06-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-23
Penalties and ownership
What sits behind the stars
Ownership
Community Living Centers, LLC
5% Or Greater Direct Ownership Interest · Organization
Community Eldercare Services, LLC
Operational/Managerial Control · Organization
Sonnier, Leland
W-2 Managing Employee · Individual
Wright, Douglas
5% Or Greater Direct Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Ahc Lexington
Lexington, TN
2-star overall rating with 2-star inspections with $18,783 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Decatur County Healthcare
Parsons, TN
4-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
Westwood Nursing and Rehabilitation
Decaturville, TN
2-star overall rating with 2-star inspections with abuse icon flag with $9,620 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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