Fayetteville, TN

Donalson Care Center

3-star overall rating with 3-star inspections with 8 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle

1681 Winchester Highway, Fayetteville, TN

(931) 433-7156

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

168

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Huntsville Hospital Health System

Operator or chain grouping

Approved since

1985-04-22

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

3 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

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

0.40

Registered nurse staffing · state 0.61 · national 0.68

LPN hours / resident day

1.26

Licensed practical nurse staffing · state 1.09 · national 0.87

Aide hours / resident day

1.94

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.60

All reported nurse hours · state 3.85 · national 3.89

Licensed hours

1.66

RN + LPN hours · state 1.70 · national 1.54

Weekend hours

3.21

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.39

Weekend registered nurse coverage · state 0.40 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.37

CMS adjusted RN staffing hours

Adjusted total hours

3.31

CMS adjusted total nurse staffing hours

Case-mix index

1.49

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

46%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,998

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

31.08

Composite VBP score used to determine payment impact.

Payment multiplier

0.9863

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.10

Baseline 18.53% · Performance 19.07% · Measure score 5.10 · Achievement 5.10 · Improvement 0

Healthcare-associated infections

1.34

Baseline 8.44% · Performance 7.81% · Measure score 1.34 · Achievement 0 · Improvement 1.34

Total nurse turnover

4.80

Baseline 41.67% · Performance 44.05% · Measure score 4.80 · Achievement 4.80 · Improvement 0

Adjusted total nurse staffing

1.19

Baseline 2.76 hours · Performance 3.27 hours · Measure score 1.19 · Achievement 0.69 · Improvement 1.19

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.76%	10.72% 1 pts worse	No Different than the National Rate · Eligible stays 166 · Observed rate 12.05% · Lower 95% interval 7.99%
Discharge to community	57.58%	50.57% 7 pts better	Better than the National Rate · Eligible stays 152 · Observed rate 54.61% · Lower 95% interval 51.45%
Medicare spending per beneficiary	1.12	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 108 · Denominator 108
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 108
Discharge self-care score	66.23%	53.69% 12.5 pts better	Numerator 51 · Denominator 77
Discharge mobility score	51.95%	50.94% 1 pts better	Numerator 40 · Denominator 77
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 108 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.81%	7.12% 0.7 pts worse	No Different than the National Rate · Eligible stays 101 · Observed rate 7.92% · Lower 95% interval 4.24%
Staff COVID-19 vaccination coverage	0.98%	8.2% 7.2 pts worse	Numerator 1 · Denominator 102
Staff flu vaccination coverage	51.92%	42% 9.9 pts better	Numerator 54 · Denominator 104
Discharge function score	63.64%	56.45% 7.2 pts better	Numerator 49 · Denominator 77
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 27 · Denominator 27
Transfer of health information to patient	97.83%	96.28% 1.5 pts better	Numerator 45 · Denominator 46
Resident COVID-19 vaccinations up to date	17.86%	25.2% 7.3 pts worse	Numerator 10 · Denominator 56

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 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.9	1.6 1.3 pts worse	1.8 1.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.6 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	77.5%	89.9% 12.4 pts worse	93.4% 15.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 78.2% · Q2 77.6% · Q3 77.8% · Q4 76.4% · 4Q avg 77.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	93.8%	94.5% 0.7 pts worse	95.5% 1.7 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 93.8%
Percentage of long-stay residents experiencing one or more falls with major injury	2.3%	3.6% 1.3 pts better	3.3% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.6% · Q3 2.8% · Q4 1.4% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.3%	11.8% 8.5 pts better	11.4% 8.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 2.8% · Q3 3.0% · Q4 0.0% · 4Q avg 3.3%
Percentage of long-stay residents who lose too much weight	8.9%	6.2% 2.7 pts worse	5.4% 3.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 11.8% · Q3 8.8% · Q4 7.8% · 4Q avg 8.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	26.1%	32.2% 6.1 pts better	19.6% 6.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 26.4% · Q3 23.5% · Q4 26.2% · 4Q avg 26.1%
Percentage of long-stay residents who received an antipsychotic medication	19.3%	18.1% 1.2 pts worse	16.7% 2.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 19.6% · Q3 18.5% · Q4 21.1% · 4Q avg 19.3% · 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	16.9%	19.9% 3 pts better	16.3% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 16.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	17.3%	15.3% 2 pts worse	14.9% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.8% · Q2 17.7% · Q3 8.5% · Q4 7.0% · 4Q avg 17.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.9%	0.9% About the same	1.0% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 1.1% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.8%	1.9% 0.9 pts worse	1.7% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 4.2% · Q3 2.8% · Q4 1.4% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	14.1%	20.2% 6.1 pts better	19.8% 5.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 17.4% · Q3 14.9% · Q4 12.7% · 4Q avg 14.1%
Percentage of long-stay residents with pressure ulcers	3.5%	5.4% 1.9 pts better	5.1% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.4% · Q3 2.5% · Q4 4.2% · 4Q avg 3.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	71.6%	79.6% 8 pts worse	81.7% 10.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 87.6% · Q2 78.8% · Q3 56.2% · Q4 59.4% · 4Q avg 71.6%
Percentage of short-stay residents who had an outpatient emergency department visit	15.4%	11.2% 4.2 pts worse	12.0% 3.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 15.7% · Expected 11.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.4%	1.6% 1.2 pts better	1.6% 1.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	86.7%	79.8% 6.9 pts better	79.7% 7 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 86.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.4%	22.2% 1.2 pts worse	23.9% 0.5 pts better	Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 22.5% · Expected 22.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-12 · Fire 2025-03-12

8 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

12 fire-safety deficiencies

Top issue: Emergency Preparedness (10 deficiencies)

Cycle 2 Health 2021-06-30 · Fire 2021-06-30

8 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2019-07-15 · Fire 2019-07-15

8 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-03-12

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2025-04-26

D · Potential for more than minimal harm 2025-03-12

E20 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures including evacuation.

Corrected 2025-04-26

D · Potential for more than minimal harm 2025-03-12

E22 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for sheltering.

Corrected 2025-04-26

D · Potential for more than minimal harm 2025-03-12

E24 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for volunteers.

Corrected 2025-04-26

D · Potential for more than minimal harm 2025-03-12

E25 · Emergency Preparedness Deficiencies

Fire Safety

Create arrangements with other facilities to receive patients.

Corrected 2025-04-26

D · Potential for more than minimal harm 2025-03-12

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2025-04-26

D · Potential for more than minimal harm 2025-03-12

E30 · Emergency Preparedness Deficiencies

Fire Safety

List the names and contact information of those in the facility.

Corrected 2025-04-26

D · Potential for more than minimal harm 2025-03-12

E31 · Emergency Preparedness Deficiencies

Fire Safety

Provide emergency officials' contact information.

Corrected 2025-04-26

D · Potential for more than minimal harm 2025-03-12

E35 · Emergency Preparedness Deficiencies

Fire Safety

Provide family notifications of emergency plan.

Corrected 2025-04-26

D · Potential for more than minimal harm 2025-03-12

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2025-04-26

D · Potential for more than minimal harm 2025-03-12

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-04-26

D · Potential for more than minimal harm 2025-03-12

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-04-26

D · Potential for more than minimal harm 2019-07-15

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2019-07-08

D · Potential for more than minimal harm 2019-07-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-08-28

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-03-12

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 2025-04-26

D · Potential for more than minimal harm 2025-03-12

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-04-26

D · Potential for more than minimal harm 2025-03-12

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 2025-04-26

D · Potential for more than minimal harm 2025-03-12

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-04-26

D · Potential for more than minimal harm 2025-03-12

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 2025-04-26

D · Potential for more than minimal harm 2025-03-12

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 2025-04-26

D · Potential for more than minimal harm 2025-03-12

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 2025-04-26

D · Potential for more than minimal harm 2025-03-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-26

E · Potential for more than minimal harm 2021-06-30

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2021-08-12

D · Potential for more than minimal harm 2021-06-30

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 2021-08-12

D · Potential for more than minimal harm 2021-06-30

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2021-08-12

D · Potential for more than minimal harm 2021-06-30

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 2021-08-12

D · Potential for more than minimal harm 2021-06-30

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 2021-08-12

D · Potential for more than minimal harm 2021-06-30

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 2021-08-12

D · Potential for more than minimal harm 2021-06-30

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2021-08-12

D · Potential for more than minimal harm 2021-06-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-08-12

K · Immediate jeopardy 2019-07-15

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 2019-08-19

K · Immediate jeopardy 2019-07-15

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 2019-08-19

K · Immediate jeopardy 2019-07-15

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2019-08-19

K · Immediate jeopardy 2019-07-15

F841 · Nursing and Physician Services Deficiencies

Health

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

Corrected 2019-08-19

K · Immediate jeopardy 2019-07-15

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2019-08-19

E · Potential for more than minimal harm 2019-07-15

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 2019-08-19

D · Potential for more than minimal harm 2019-07-15

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2019-08-19

D · Potential for more than minimal harm 2019-07-15

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 2019-08-19

Penalties and ownership