Cycle 1
Health 2025-01-14 · Fire 2025-01-14
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Lafollette, TN
Cumberland Village Care
4-star overall rating with 4-star inspections with $18,769 in total fines with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
136 Davis Lane, Lafollette, TN
(423) 562-0760
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
182
Certified beds
Average residents
149
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1992-01-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
193 facilities
Chain averages 2 overall / 2 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
0.37
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.79
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.12
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.66
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.08
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
0.33
CMS adjusted RN staffing hours
Adjusted total hours
2.74
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,010
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9836
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.65% · Performance 22.96% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.97% · Performance 7.97% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 30.33% · Performance 21.19% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
0
Baseline 2.97 hours · Performance 3.11 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.72% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 91 · Observed rate 17.58% · Lower 95% interval 8.48% |
| Discharge to community | 41.86% |
50.57%
8.7 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 33.33% · Lower 95% interval 29.04% |
| Medicare spending per beneficiary | 1.83 |
1.02
0.8 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 84 · Denominator 84 |
| Falls with major injury | 3.57% |
0.77%
2.8 pts worse
|
Numerator 3 · Denominator 84 |
| Discharge self-care score | 39.22% |
53.69%
14.5 pts worse
|
Numerator 20 · Denominator 51 |
| Discharge mobility score | 29.41% |
50.94%
21.5 pts worse
|
Numerator 15 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 7.14% |
2.29%
4.8 pts worse
|
Numerator 6 · Denominator 84 · Adjusted rate 6.63% |
| Healthcare-associated infections requiring hospitalization | 7.97% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 9.84% · Lower 95% interval 4.38% |
| Staff COVID-19 vaccination coverage | 2.05% |
8.2%
6.1 pts worse
|
Numerator 3 · Denominator 146 |
| Staff flu vaccination coverage | 82.81% |
42%
40.8 pts better
|
Numerator 159 · Denominator 192 |
| Discharge function score | 39.22% |
56.45%
17.2 pts worse
|
Numerator 20 · Denominator 51 |
| Transfer of health information to provider | 97.73% |
95.95%
1.8 pts better
|
Numerator 43 · Denominator 44 |
| 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 | 35.19% |
25.2%
10 pts better
|
Numerator 19 · Denominator 54 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.6
0.1 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.6
0.7 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
89.9%
9.9 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.3% · 4Q avg 99.8% |
| 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 | 5.7% |
3.6%
2.1 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 7.1% · Q3 5.8% · Q4 2.8% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 37.1% |
11.8%
25.3 pts worse
|
11.4%
25.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 27.6% · Q3 49.6% · Q4 65.4% · 4Q avg 37.1% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
6.2%
5 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 1.6% · Q4 1.6% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.8% |
32.2%
5.4 pts better
|
19.6%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 29.7% · Q3 23.6% · Q4 27.3% · 4Q avg 26.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.0% |
18.1%
3.9 pts worse
|
16.7%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 19.4% · Q3 23.7% · Q4 20.0% · 4Q avg 22.0% · 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 | 11.6% |
19.9%
8.3 pts better
|
16.3%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 12.8% · Q3 7.4% · Q4 5.9% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.7% |
15.3%
0.6 pts better
|
14.9%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 16.4% · Q3 10.5% · Q4 5.6% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · 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 | 6.1% |
20.2%
14.1 pts better
|
19.8%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 7.8% · Q3 2.1% · Q4 2.1% · 4Q avg 6.1% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.4%
About the same
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 9.1% · Q3 4.7% · Q4 2.7% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
79.6%
13.9 pts better
|
81.7%
11.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 92.0% · Q3 92.6% · Q4 93.6% · 4Q avg 93.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
11.2%
3.3 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 8.0% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.6%
About the same
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.0% |
79.8%
15.2 pts better
|
79.7%
15.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.0% |
22.2%
3.8 pts worse
|
23.9%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.0% · Observed 25.3% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-10-20 · Fire 2021-10-20
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-10-29 · Fire 2019-10-29
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-18
F · Potential for more than minimal harm
2025-01-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-18
F · Potential for more than minimal harm
2025-01-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-18
F · Potential for more than minimal harm
2025-01-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-18
E · Potential for more than minimal harm
2025-01-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-18
F · Potential for more than minimal harm
2019-10-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-12-06
E · Potential for more than minimal harm
2019-10-29
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-12-06
D · Potential for more than minimal harm
2019-10-29
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 2019-12-06
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-30
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-02-19
E · Potential for more than minimal harm
2025-01-14
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 2025-02-18
D · Potential for more than minimal harm
2025-01-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-14
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-18
D · Potential for more than minimal harm
2024-10-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-09-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-29
D · Potential for more than minimal harm
2023-04-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-05-03
D · Potential for more than minimal harm
2021-10-20
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 2021-11-23
F · Potential for more than minimal harm
2019-10-29
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 2019-12-06
F · Potential for more than minimal harm
2019-10-29
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2019-12-06
D · Potential for more than minimal harm
2019-10-29
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2019-12-06
D · Potential for more than minimal harm
2019-10-29
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 2019-12-06
D · Potential for more than minimal harm
2019-10-29
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2019-12-06
D · Potential for more than minimal harm
2019-10-29
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 2019-12-06
D · Potential for more than minimal harm
2019-10-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-06
Penalties and ownership
What sits behind the stars
$18,769
2024-09-11
Fine
Fine · fine $18,769
Fine
Ownership
Regency Health Services, LLC
5% Or Greater Direct Ownership Interest · Organization
Berg, Michael
Corporate Officer · Individual
Bridgeford, Laura
Corporate Officer · Individual
Fc-Gen Operations Investment LLC
5% Or Greater Indirect Ownership Interest · Organization
Fishman, Steven
5% Or Greater Indirect Ownership Interest · Individual
Flowers, Rob
Operational/Managerial Control · Individual
Gen Operations I LLC
5% Or Greater Indirect Ownership Interest · Organization
Gen Operations Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hccf Management Group Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Mansour, Elie
Operational/Managerial Control · Individual
Mendelson, Avi
Corporate Officer · Individual
Sun Healthcare Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Sunbridge Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Sundance Rehabilitation Holdco Inc
5% Or Greater Indirect Ownership Interest · Organization
Welltower Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Whitman, Arnold
5% Or Greater Indirect Ownership Interest · Individual
Zac Properties Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Tennova Lafollette Health And Rehab Center
Lafollette, TN
4-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Rocky Top Care Center
Rocky Top, TN
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $86,768 in total fines with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Andersonville Tn Opco LLC
Andersonville, TN
2-star overall rating with 3-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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