Cycle 1
Health 2022-05-11 · Fire 2022-05-11
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Murfreesboro, TN
Community Care Of Rutherford
1-star overall rating with 1-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
901 County Farm Rd, Murfreesboro, TN
(615) 893-2624
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
131
Certified beds
Average residents
93
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-07-01
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
0.64
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
2.36
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.21
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.85
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.81
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.88
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
5,203
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9903
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.53
Baseline 19.22% · Performance 18.87% · Measure score 5.53 · Achievement 5.53 · Improvement 1.10
Healthcare-associated infections
1.43
Baseline 7.15% · Performance 7.41% · Measure score 1.43 · Achievement 1.43 · Improvement 0
Total nurse turnover
6.11
Baseline 28.89% · Performance 38.71% · Measure score 6.11 · Achievement 6.11 · Improvement 0
Adjusted total nurse staffing
1.75
Baseline 3.94 hours · Performance 3.58 hours · Measure score 1.75 · Achievement 1.75 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.31% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 147 · Observed rate 7.48% · Lower 95% interval 6.4% |
| Discharge to community | 55.1% |
50.57%
4.5 pts better
|
No Different than the National Rate · Eligible stays 109 · Observed rate 49.54% · Lower 95% interval 47.26% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.99% |
95.27%
3.7 pts better
|
Numerator 98 · Denominator 99 |
| Falls with major injury | 2.02% |
0.77%
1.2 pts worse
|
Numerator 2 · Denominator 99 |
| Discharge self-care score | 39.06% |
53.69%
14.6 pts worse
|
Numerator 25 · Denominator 64 |
| Discharge mobility score | 46.88% |
50.94%
4.1 pts worse
|
Numerator 30 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 6.06% |
2.29%
3.8 pts worse
|
Numerator 6 · Denominator 99 · Adjusted rate 5.66% |
| Healthcare-associated infections requiring hospitalization | 7.41% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 8.24% · Lower 95% interval 4.29% |
| Staff COVID-19 vaccination coverage | 2.84% |
8.2%
5.4 pts worse
|
Numerator 4 · Denominator 141 |
| Staff flu vaccination coverage | 13.41% |
42%
28.6 pts worse
|
Numerator 22 · Denominator 164 |
| Discharge function score | 54.69% |
56.45%
1.8 pts worse
|
Numerator 35 · Denominator 64 |
| Transfer of health information to provider | 93.02% |
95.95%
2.9 pts worse
|
Numerator 40 · Denominator 43 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 12.73% |
25.2%
12.5 pts worse
|
Numerator 7 · Denominator 55 |
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 2.3 · Expected 1.8 · 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 1.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.5% |
89.9%
4.4 pts worse
|
93.4%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.9% · Q2 87.7% · Q3 81.3% · Q4 81.2% · 4Q avg 85.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 81.1% |
94.5%
13.4 pts worse
|
95.5%
14.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 81.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
3.6%
1 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 4.9% · Q3 4.0% · Q4 1.2% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.6% |
11.8%
8.2 pts better
|
11.4%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 0.0% · Q4 11.3% · 4Q avg 3.6% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
6.2%
0.3 pts better
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 8.9% · Q3 1.7% · Q4 3.4% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.6% |
32.2%
5.6 pts better
|
19.6%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 26.3% · Q3 23.7% · Q4 25.0% · 4Q avg 26.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.3% |
18.1%
7.2 pts worse
|
16.7%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 23.3% · Q3 24.4% · Q4 23.4% · 4Q avg 25.3% · 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 | 21.8% |
19.9%
1.9 pts worse
|
16.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.0% |
15.3%
5.3 pts better
|
14.9%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 5.7% · Q3 13.0% · Q4 7.3% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
1.9%
0.6 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.5% · Q3 2.7% · Q4 2.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.4% |
20.2%
1.8 pts better
|
19.8%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 14.5% · Q3 12.8% · Q4 13.3% · 4Q avg 18.4% |
| Percentage of long-stay residents with pressure ulcers | 7.2% |
5.4%
1.8 pts worse
|
5.1%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 7.5% · Q3 3.9% · Q4 7.0% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.3% |
79.6%
21.3 pts worse
|
81.7%
23.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 40.5% · Q2 53.0% · Q3 64.5% · Q4 71.6% · 4Q avg 58.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.2% |
11.2%
2 pts worse
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 13.3% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.6%
0.2 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.8% · Q3 0.0% · Q4 1.8% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 44.7% |
79.8%
35.1 pts worse
|
79.7%
35 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 44.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.3% |
22.2%
10.1 pts worse
|
23.9%
8.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.3% · Observed 28.9% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-12-04 · Fire 2019-12-04
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2018-08-29 · Fire 2018-08-29
3 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-05-11
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2022-06-09
D · Potential for more than minimal harm
2019-12-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-19
C · Minimal harm
2018-08-29
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2018-09-05
C · Minimal harm
2018-08-29
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2018-09-05
C · Minimal harm
2018-08-29
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2018-09-05
B · Minimal harm
2018-08-29
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 2018-09-27
B · Minimal harm
2018-08-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-09-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-03-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-16
G · Actual harm
2022-05-11
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 2022-06-03
G · Actual harm
2022-05-11
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 2022-06-03
D · Potential for more than minimal harm
2022-05-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-06-03
D · Potential for more than minimal harm
2022-05-11
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 2022-06-03
D · Potential for more than minimal harm
2022-05-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-06-03
D · Potential for more than minimal harm
2022-05-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-06-03
D · Potential for more than minimal harm
2022-05-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-06-03
D · Potential for more than minimal harm
2022-05-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-06-03
D · Potential for more than minimal harm
2022-05-11
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 2022-07-15
D · Potential for more than minimal harm
2019-12-04
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2020-01-06
D · Potential for more than minimal harm
2019-12-04
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2020-01-06
D · Potential for more than minimal harm
2019-12-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-01-06
D · Potential for more than minimal harm
2019-12-04
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2020-01-06
D · Potential for more than minimal harm
2019-12-04
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 2020-01-06
D · Potential for more than minimal harm
2018-08-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2018-09-27
D · Potential for more than minimal harm
2018-08-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2018-09-27
D · Potential for more than minimal harm
2018-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-09-27
Penalties and ownership
What sits behind the stars
Ownership
Burgess, Ernest
Corporate Director · Individual
Community Care Of Rutherford County, Inc.
Operational/Managerial Control · Organization
Cook, Carol
Corporate Director · Individual
Jernigan, Kaye
Corporate Director · Individual
Johnson, Frankie
Corporate Director · Individual
Johnson, Paul
Corporate Director · Individual
King, Charles
W-2 Managing Employee · Individual
Lyles, Bernard
Corporate Director · Individual
Nunley, Mike
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Nhc Healthcare, Murfreesboro
Murfreesboro, TN
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Stone River Post Acute
Murfreesboro, TN
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Adamsplace, LLC
Murfreesboro, TN
3-star overall rating with 2-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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