Cycle 1
Health 2023-08-02 · Fire 2023-08-02
3 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Erwin, TN
Center On Aging And Health
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
880 South Mohawk Drive, Erwin, TN
(423) 743-7669
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
67
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2001-04-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.70
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.23
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.48
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.41
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.69
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
0.07
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
4.11
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,396
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.49
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
1.46
Baseline 21.64% · Performance 20.76% · Measure score 1.46 · Achievement 1.46 · Improvement 1.42
Healthcare-associated infections
0
Baseline 8.23% · Performance 8.48% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.54
Baseline 41.67% · Performance 49.21% · Measure score 3.54 · Achievement 3.54 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.85 hours · Performance 2.98 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.89% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 13.46% · Lower 95% interval 6.93% |
| Discharge to community | 55.53% |
50.57%
5 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 51.28% · Lower 95% interval 42.84% |
| Medicare spending per beneficiary | 1.29 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 97.56% |
95.27%
2.3 pts better
|
Numerator 40 · Denominator 41 |
| Falls with major injury | 2.44% |
0.77%
1.7 pts worse
|
Numerator 1 · Denominator 41 |
| Discharge self-care score | 46.15% |
53.69%
7.5 pts worse
|
Numerator 12 · Denominator 26 |
| Discharge mobility score | 38.46% |
50.94%
12.5 pts worse
|
Numerator 10 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 41 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.48% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 15% · Lower 95% interval 3.95% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 83 |
| Staff flu vaccination coverage | 72.22% |
42%
30.2 pts better
|
Numerator 65 · Denominator 90 |
| Discharge function score | 38.46% |
56.45%
18 pts worse
|
Numerator 10 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4% |
25.2%
21.2 pts worse
|
Numerator 1 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.6
0.9 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 3.0 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
89.9%
9.7 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.4% · 4Q avg 99.6% |
| 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 | 0.9% |
3.6%
2.7 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.7% |
11.8%
1.1 pts better
|
11.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 11.1% · Q3 8.9% · Q4 5.8% · 4Q avg 10.7% |
| Percentage of long-stay residents who lose too much weight | 13.4% |
6.2%
7.2 pts worse
|
5.4%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 18.8% · Q3 7.0% · Q4 17.0% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 59.0% |
32.2%
26.8 pts worse
|
19.6%
39.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.0% · Q2 56.2% · Q3 60.5% · Q4 68.8% · 4Q avg 59.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 37.2% |
18.1%
19.1 pts worse
|
16.7%
20.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.7% · Q2 42.1% · Q3 31.7% · Q4 30.4% · 4Q avg 37.2% · 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 | 24.9% |
19.9%
5 pts worse
|
16.3%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.5% |
15.3%
0.2 pts worse
|
14.9%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 13.3% · Q3 4.9% · Q4 19.1% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.4% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.9%
0.3 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.3% · Q3 3.6% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.8% |
20.2%
0.6 pts worse
|
19.8%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 21.3% · Q3 23.9% · Q4 19.2% · 4Q avg 20.8% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
5.4%
1.4 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 9.1% · Q3 5.9% · Q4 7.7% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
79.6%
17.5 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 95.5% · Q3 98.7% · Q4 97.1% · 4Q avg 97.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
11.2%
0.7 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 13.3% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.6%
0.7 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.7% · Q3 2.1% · Q4 2.4% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
79.8%
14.5 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.0% |
22.2%
1.8 pts worse
|
23.9%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 36.7% · Expected 36.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-11-06 · Fire 2019-11-06
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2018-09-26 · Fire 2018-09-26
1 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-08-02
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-08-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-28
F · Potential for more than minimal harm
2019-11-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-22
F · Potential for more than minimal harm
2018-09-26
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2018-10-26
F · Potential for more than minimal harm
2018-09-26
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2018-10-26
D · Potential for more than minimal harm
2018-09-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-10-26
C · Minimal harm
2018-09-26
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2018-10-26
C · Minimal harm
2018-09-26
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2018-10-26
C · Minimal harm
2018-09-26
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2018-10-26
C · Minimal harm
2018-09-26
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2018-10-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-04
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 2025-06-16
D · Potential for more than minimal harm
2023-08-02
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-02
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 2023-09-01
D · Potential for more than minimal harm
2019-11-06
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 2019-11-27
D · Potential for more than minimal harm
2019-11-06
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 2019-11-27
D · Potential for more than minimal harm
2018-09-26
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2018-10-26
Penalties and ownership
What sits behind the stars
Ownership
Einhorn, Neal
5% Or Greater Direct Ownership Interest · Individual
Weiss, Martin
5% Or Greater Direct Ownership Interest · Individual
Broad River Rehabilitation
Operational/Managerial Control · Organization
Burlison, Robert
Operational/Managerial Control · Individual
Chandler, Jason
Operational/Managerial Control · Individual
Collins, Stoney
Operational/Managerial Control · Individual
Cox, Carol
Operational/Managerial Control · Individual
Daniel, Anton
Operational/Managerial Control · Individual
Einhorn, Neal
Operational/Managerial Control · Individual
Einhorn, Neal
Corporate Director · Individual
Einhorn, Neal
Corporate Officer · Individual
Gaddy, Christopher
Operational/Managerial Control · Individual
Griffin, Cynthia
Operational/Managerial Control · Individual
Hirt, Annette
Operational/Managerial Control · Individual
Holtsclaw, Jamie
Operational/Managerial Control · Individual
Hopson, Bethany
Operational/Managerial Control · Individual
Horton, Brandie
Operational/Managerial Control · Individual
Hubbard, Eva
Operational/Managerial Control · Individual
Hunt, Jana
Operational/Managerial Control · Individual
Jackson, Melissa
Operational/Managerial Control · Individual
Lawrence, Rebecca
Operational/Managerial Control · Individual
Miller, Janice
Operational/Managerial Control · Individual
Penley, Valarie
Operational/Managerial Control · Individual
Powers, Candy
Operational/Managerial Control · Individual
Shadrick, Sharon
Operational/Managerial Control · Individual
Stancil, Tanya
Operational/Managerial Control · Individual
Weiss, Martin
Limited Partnership Interest · Individual
Nearby options
Other facilities in reach
#1
Christian Care Center Of Unicoi County
Erwin, TN
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Erwin Health Care Center
Erwin, TN
1-star overall rating with 2-star inspections with $10,024 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Four Oaks Health Care Center
Jonesborough, TN
3-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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