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

Staffing

Hours and turnover

RN hours / resident day

0.40

Registered nurse staffing

LPN hours / resident day

1.26

Licensed practical nurse staffing

Aide hours / resident day

1.94

Nurse aide staffing

Weekend hours

3.21

Weekend nurse staffing

RN turnover

50%

Annual RN turnover

Total nurse turnover

46%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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