Cycle 1
Health 2021-09-10 · Fire 2021-09-10
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lawrenceburg, TN
Countryside Post-Acute And Rehabilitation Center
2-star overall rating with 2-star inspections with 9 recent health deficiencies
3051 Buffalo Road, Lawrenceburg, TN
(931) 762-7518
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
162
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Plainview Healthcare Partners
Operator or chain grouping
Approved since
1992-03-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 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
0.25
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.24
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.49
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.98
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.43
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.23
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,536
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.8
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.72% · Performance 21.77% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.19% · Performance 8.09% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.76
Baseline 59.55% · Performance 52.38% · Measure score 2.76 · Achievement 2.76 · Improvement 1.57
Adjusted total nurse staffing
1.96
Baseline 2.52 hours · Performance 3.32 hours · Measure score 1.96 · Achievement 0.86 · Improvement 1.96
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.02% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 22.03% · Lower 95% interval 8.68% |
| Discharge to community | 54.07% |
50.57%
3.5 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 45.95% · Lower 95% interval 35.39% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 69.23% |
95.27%
26 pts worse
|
Numerator 27 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 39.39% |
53.69%
14.3 pts worse
|
Numerator 13 · Denominator 33 |
| Discharge mobility score | 42.42% |
50.94%
8.5 pts worse
|
Numerator 14 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 5.13% |
2.29%
2.8 pts worse
|
Numerator 2 · Denominator 39 · Adjusted rate 3.59% |
| Healthcare-associated infections requiring hospitalization | 8.09% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 10.87% · Lower 95% interval 4.03% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 137 |
| Staff flu vaccination coverage | 16.79% |
42%
25.2 pts worse
|
Numerator 23 · Denominator 137 |
| Discharge function score | 51.52% |
56.45%
4.9 pts worse
|
Numerator 17 · Denominator 33 |
| 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 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.35% |
25.2%
20.9 pts worse
|
Numerator 1 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.6
0.4 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.6
0.5 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.7% |
89.9%
3.8 pts better
|
93.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.2% · Q2 91.9% · Q3 94.3% · Q4 97.6% · 4Q avg 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.9% |
94.5%
0.6 pts worse
|
95.5%
1.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.6%
0.7 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 3.5% · Q3 2.3% · Q4 1.2% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 53.5% |
11.8%
41.7 pts worse
|
11.4%
42.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 61.8% · Q2 56.7% · Q3 44.4% · Q4 50.0% · 4Q avg 53.5% |
| Percentage of long-stay residents who lose too much weight | 5.5% |
6.2%
0.7 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 8.7% · Q3 1.4% · Q4 6.6% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.4% |
32.2%
5.8 pts better
|
19.6%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 24.3% · Q3 27.4% · Q4 27.6% · 4Q avg 26.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.7% |
18.1%
6.6 pts worse
|
16.7%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 25.0% · Q3 22.0% · Q4 26.8% · 4Q avg 24.7% · 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 | 2.9% |
19.9%
17 pts better
|
16.3%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 8.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.8% |
15.3%
13.5 pts better
|
14.9%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.0% · Q3 1.4% · Q4 0.0% · 4Q avg 1.8% · 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 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.9%
1.3 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.1% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.2% |
20.2%
About the same
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 18.3% · Q3 25.8% · Q4 15.2% · 4Q avg 20.2% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.4%
1 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 4.6% · Q3 3.3% · Q4 3.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.4% |
79.6%
21.2 pts worse
|
81.7%
23.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 37.8% · Q2 60.0% · Q3 66.7% · Q4 66.7% · 4Q avg 58.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.1% |
11.2%
1.9 pts worse
|
12.0%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 14.0% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.6%
0.5 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 3.8% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 55.8% |
79.8%
24 pts worse
|
79.7%
23.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 55.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.2% |
22.2%
5 pts better
|
23.9%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 18.6% · Expected 25.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-12-18 · Fire 2019-12-18
4 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2019-02-06 · Fire 2019-02-06
0 health deficiencies
No concentrated health issue counts in this cycle.
15 fire-safety deficiencies
Top issue: Emergency Preparedness (12 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2019-12-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-01-21
F · Potential for more than minimal harm
2019-12-18
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-01-21
F · Potential for more than minimal harm
2019-12-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-18
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-02-06
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-03-06
D · Potential for more than minimal harm
2019-02-06
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-03-06
D · Potential for more than minimal harm
2019-02-06
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2019-03-06
D · Potential for more than minimal harm
2019-02-06
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2019-03-06
D · Potential for more than minimal harm
2019-02-06
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2019-03-06
D · Potential for more than minimal harm
2019-02-06
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2019-03-06
D · Potential for more than minimal harm
2019-02-06
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2019-03-06
D · Potential for more than minimal harm
2019-02-06
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2019-03-06
D · Potential for more than minimal harm
2019-02-06
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2019-03-06
D · Potential for more than minimal harm
2019-02-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-03-06
D · Potential for more than minimal harm
2019-02-06
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2019-03-06
D · Potential for more than minimal harm
2019-02-06
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2019-03-06
D · Potential for more than minimal harm
2019-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-03-06
D · Potential for more than minimal harm
2019-02-06
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 2019-03-06
D · Potential for more than minimal harm
2019-02-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-03-06
Inspection history
Recent health citations
F · Potential for more than minimal harm
2021-09-10
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 2021-10-25
E · Potential for more than minimal harm
2021-09-10
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2021-10-25
D · Potential for more than minimal harm
2021-09-10
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 2021-10-25
D · Potential for more than minimal harm
2021-09-10
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2021-10-25
D · Potential for more than minimal harm
2021-09-10
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 2021-10-25
D · Potential for more than minimal harm
2021-09-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-10-25
D · Potential for more than minimal harm
2021-09-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-10-25
D · Potential for more than minimal harm
2021-09-10
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2021-10-25
D · Potential for more than minimal harm
2021-09-10
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2021-10-25
E · Potential for more than minimal harm
2019-12-18
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 2020-01-21
E · Potential for more than minimal harm
2019-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-01-21
Penalties and ownership
What sits behind the stars
Ownership
Countryside Tn Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Amoyelle, Yechezkel
5% Or Greater Indirect Ownership Interest · Individual
Fogel, Joshua
5% Or Greater Indirect Ownership Interest · Individual
Fogel, Joshua
Operational/Managerial Control · Individual
Fogel, Joshua
Corporate Officer · Individual
Wallace, Sara
W-2 Managing Employee · Individual
Weiss, Naftali
5% Or Greater Indirect Ownership Interest · Individual
Weiss, Naftali
Operational/Managerial Control · Individual
Weiss, Naftali
Corporate Officer · Individual
Wf Countryside Tn LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Nhc Healthcare, Scott
Lawrenceburg, TN
5-star overall rating with 4-star inspections with 1 recent health deficiencies
#2
Nhc Healthcare, Lawrenceburg
Lawrenceburg, TN
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Mt Pleasant Healthcare And Rehabilitation
Mount Pleasant, TN
3-star overall rating with 3-star inspections with $7,443 in total fines with 7 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
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