Cycle 1
Health 2025-09-04 · Fire 2025-09-04
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Celina, TN
Celina Health And Rehabilitation Center
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
120 Pitcock Lane, Celina, TN
(931) 243-3139
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
78
Certified beds
Average residents
58
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Twin Rivers Health & Rehabilitation
Operator or chain grouping
Approved since
2002-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 4 overall / 4 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
0.51
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.76
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.16
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
2.91
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.00
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
45%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,359
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.99
Composite VBP score used to determine payment impact.
Payment multiplier
0.9844
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.56
Baseline 22.71% · Performance 19.83% · Measure score 4.56 · Achievement 3.45 · Improvement 4.56
Healthcare-associated infections
0.62
Baseline 8.45% · Performance 8.06% · Measure score 0.62 · Achievement 0 · Improvement 0.62
Total nurse turnover
4.81
Baseline 46.67% · Performance 44.00% · Measure score 4.81 · Achievement 4.81 · Improvement 0.72
Adjusted total nurse staffing
0.80
Baseline 2.75 hours · Performance 3.14 hours · Measure score 0.80 · Achievement 0 · Improvement 0.80
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.2% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 8.86% · Lower 95% interval 6.5% |
| Discharge to community | 38.73% |
50.57%
11.8 pts worse
|
Worse than the National Rate · Eligible stays 67 · Observed rate 31.34% · Lower 95% interval 27.92% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 91.67% |
95.27%
3.6 pts worse
|
Numerator 55 · Denominator 60 |
| Falls with major injury | 5% |
0.77%
4.2 pts worse
|
Numerator 3 · Denominator 60 |
| Discharge self-care score | 32% |
53.69%
21.7 pts worse
|
Numerator 16 · Denominator 50 |
| Discharge mobility score | 38% |
50.94%
12.9 pts worse
|
Numerator 19 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 1.67% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 60 · Adjusted rate 1.28% |
| Healthcare-associated infections requiring hospitalization | 8.06% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 9.09% · Lower 95% interval 3.76% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 82 |
| Staff flu vaccination coverage | 61.95% |
42%
20 pts better
|
Numerator 70 · Denominator 113 |
| Discharge function score | 44% |
56.45%
12.5 pts worse
|
Numerator 22 · Denominator 50 |
| 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 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 5.56% |
25.2%
19.6 pts worse
|
Numerator 2 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.6 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.6
0.2 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · 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 | 7.3% |
3.6%
3.7 pts worse
|
3.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 6.1% · Q3 8.7% · Q4 6.2% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
11.8%
11.2 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 8.3% |
6.2%
2.1 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 12.8% · Q3 8.1% · Q4 6.1% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.6% |
32.2%
13.6 pts better
|
19.6%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 23.4% · Q3 18.2% · Q4 12.8% · 4Q avg 18.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.4% |
18.1%
3.7 pts better
|
16.7%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 18.9% · Q3 9.1% · Q4 10.5% · 4Q avg 14.4% · 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 | 10.2% |
19.9%
9.7 pts better
|
16.3%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.8% |
15.3%
7.5 pts worse
|
14.9%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 21.4% · Q3 20.0% · Q4 26.2% · 4Q avg 22.8% · 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 | 4.4% |
1.9%
2.5 pts worse
|
1.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 6.5% · Q3 4.7% · Q4 2.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.0% |
20.2%
7.8 pts worse
|
19.8%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.2% · Q2 31.4% · Q3 16.6% · Q4 38.6% · 4Q avg 28.0% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
5.4%
4.9 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.5% · 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 | 6.3% |
11.2%
4.9 pts better
|
12.0%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 5.7% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.8% |
1.6%
2.2 pts worse
|
1.6%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.9% · Q3 6.2% · Q4 3.2% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
79.8%
20.2 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.3% |
22.2%
9.9 pts better
|
23.9%
11.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 11.3% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-24 · Fire 2022-08-24
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-07-23 · Fire 2019-07-23
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-04
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 2025-10-01
E · Potential for more than minimal harm
2025-09-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-09-04
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-09-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-09-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-01
D · Potential for more than minimal harm
2022-08-24
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 2022-09-23
D · Potential for more than minimal harm
2022-08-24
K223 · Egress Deficiencies
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 2022-09-23
E · Potential for more than minimal harm
2019-07-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-08-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-04
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 2025-10-01
D · Potential for more than minimal harm
2025-09-04
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-10-01
E · Potential for more than minimal harm
2022-08-24
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 2022-09-23
D · Potential for more than minimal harm
2022-08-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-23
D · Potential for more than minimal harm
2022-08-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-09-23
D · Potential for more than minimal harm
2019-07-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-23
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 2019-08-23
Penalties and ownership
What sits behind the stars
Ownership
J-M Investments, LLC
5% Or Greater Direct Ownership Interest · Organization
Irrevocable Grantor Trust Agreement Of John J Sheehan, Jr
5% Or Greater Indirect Ownership Interest · Organization
Irrevocable Grantor Trust Agreement Of Margaret Phillips Sheehan
5% Or Greater Indirect Ownership Interest · Organization
Copeland, Jessie
Operational/Managerial Control · Individual
Copeland, Jessie
Corporate Director · Individual
Davis, Clinton
Operational/Managerial Control · Individual
Holcombe, Michelle
Operational/Managerial Control · Individual
J-M Investments, LLC
Operational/Managerial Control · Organization
Pioneer Consulting LLC
Operational/Managerial Control · Organization
Sheehan, John
Operational/Managerial Control · Individual
Sheehan, John
Corporate Officer · Individual
Tandy, Rebecca
Operational/Managerial Control · Individual
Tandy, Rebecca
Corporate Director · Individual
Twin Rivers Health & Rehabilitation LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Mabry Health Care
Gainesboro, TN
3-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Overton County Health And Rehab Center
Livingston, TN
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Signature Healthcare of Monroe County Rehab and We
Tompkinsville, KY
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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